Healthcare Provider Details

I. General information

NPI: 1750546412
Provider Name (Legal Business Name): DERRICK WAYNE SMITH MD, LMHCA, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: D. WAYNE SMITH

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 11/15/2024
Certification Date: 11/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7500 BANNER WAY NE
SEATTLE WA
98115-4176
US

IV. Provider business mailing address

507 BROMPTON LN
BOSSIER CITY LA
71111-8208
US

V. Phone/Fax

Practice location:
  • Phone: 206-427-4679
  • Fax:
Mailing address:
  • Phone: 818-515-7991
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD.61597266
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: