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General NPI Number Information
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NPI Number | 1144671884
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Entity Type | Individual
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Provider Name | DEREK JAMES SMITH PH.D.
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Gender | Male
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Dates
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Enumeration Date | 06/23/2016
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Last Update Date | 05/04/2021
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Provider Practice Location Address
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Address Line | 2853 E BENT TREE LN
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City | HARRISON
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State | ID
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Zip | 83833-8674
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Country | US
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Telephone | 208-755-7393
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Fax |
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Provider Business Mailing Address
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Address Line | 2853 E BENT TREE LN
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City | HARRISON
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State | ID
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Zip | 83833-8674
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Country | US
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Telephone | 208-755-7393
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY-203364
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 11022713-2501
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License Number State | UT
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