Individual
EDWARD MICHAEL SMITH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LPC-IT
Contact information
Practice address
W350S1401 WATERVILLE RD, DOUSMAN, WI 53118-9020
(920) 253-1862
Mailing address
W350S1401 WATERVILLE RD, DOUSMAN, WI 53118-9020
(920) 253-1862
Taxonomy
Speciality
Code
Description
License number
State
101YM0800X
Mental Health Counselor
Primary
265001
WI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100060402
—
WI
05
—
1114196854
—
WI
Enumeration date
02/05/2020
Last updated
02/10/2020
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