Healthcare Provider Details

I. General information

NPI: 1407022692
Provider Name (Legal Business Name): CHRIS SMITH MDIV LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 W MAIN ST
PORT WASHINGTON WI
53074-0994
US

IV. Provider business mailing address

121 W MAIN ST
PORT WASHINGTON WI
53074-0994
US

V. Phone/Fax

Practice location:
  • Phone: 262-284-8200
  • Fax: 262-284-8104
Mailing address:
  • Phone: 262-284-8200
  • Fax: 262-284-8104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number68124
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: