Provider Demographics
NPI:1386130920
Name:SMITH, TOMMY WAYNE
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:WAYNE
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 1:1305 MCMILLAN AVE
Mailing Address - Street 2:
Mailing Address - City:BREWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36426-1324
Mailing Address - Country:US
Mailing Address - Phone:251-809-3191
Mailing Address - Fax:251-809-8215
Practice Address - Street 1:1305 MCMILLAN AVE
Practice Address - Street 2:
Practice Address - City:BREWTON
Practice Address - State:AL
Practice Address - Zip Code:36426-1324
Practice Address - Country:US
Practice Address - Phone:251-809-3191
Practice Address - Fax:251-809-8215
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL224106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist