Provider Demographics
NPI:1154007573
Name:SMITH, WILSON SHADWELL
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:SHADWELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1565 PLUTO ROAD
Mailing Address - Street 2:
Mailing Address - City:SHADY SPRING
Mailing Address - State:WV
Mailing Address - Zip Code:25918
Mailing Address - Country:US
Mailing Address - Phone:304-719-9144
Mailing Address - Fax:
Practice Address - Street 1:25 MALLARD COURT
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801
Practice Address - Country:US
Practice Address - Phone:304-255-7526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-22
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical