=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558742361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SYDNEY NICHOLE SMITH MSW, LSWAIC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2015
-----------------------------------------------------
Last Update Date | 07/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36106 48TH AVE S
-----------------------------------------------------
City | ROY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98580-7908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-380-6142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 36106 48TH AVE S
-----------------------------------------------------
City | ROY
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98580-7908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-380-6142
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | SC60842799
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------