Healthcare Provider Details

I. General information

NPI: 1932812617
Provider Name (Legal Business Name): IAN KENNETH SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/28/2022
Last Update Date: 12/28/2022
Certification Date: 12/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3113 E WASHINGTON AVE
MADISON WI
53704-4330
US

IV. Provider business mailing address

3113 E WASHINGTON AVE
MADISON WI
53704-4330
US

V. Phone/Fax

Practice location:
  • Phone: 608-416-5777
  • Fax:
Mailing address:
  • Phone: 608-416-5777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: