Provider Demographics
NPI:1124321989
Name:SMITH, DOUGLAS EDWARD (BS)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 876742
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-6742
Mailing Address - Country:US
Mailing Address - Phone:907-952-8773
Mailing Address - Fax:907-357-6865
Practice Address - Street 1:5431 E MAYFLOWER LN
Practice Address - Street 2:SUITE 5
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7891
Practice Address - Country:US
Practice Address - Phone:907-357-6860
Practice Address - Fax:907-357-6865
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)