Provider Demographics
NPI:1306976527
Name:SMITH, JOE WILLIE JR (BA)
Entity type:Individual
Prefix:MR
First Name:JOE
Middle Name:WILLIE
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5128 N 56TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4214
Mailing Address - Country:US
Mailing Address - Phone:414-587-0508
Mailing Address - Fax:414-463-0873
Practice Address - Street 1:6040 W LISBON AVE STE 200
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-2116
Practice Address - Country:US
Practice Address - Phone:414-447-9890
Practice Address - Fax:414-447-9891
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI101Y00000X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor