Provider Demographics
NPI:1528429123
Name:SMITH, TIMOTHY E (LSW)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 WEST PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053
Mailing Address - Country:US
Mailing Address - Phone:440-989-4987
Mailing Address - Fax:
Practice Address - Street 1:2115 WEST PARK DRIVE
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053
Practice Address - Country:US
Practice Address - Phone:440-989-4987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-10
Last Update Date:2018-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS0901027101YA0400X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHS0901027OtherLICENSE