Provider Demographics
NPI:1992943385
Name:SMITH, PHILLIP
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 N IRON BRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-4932
Mailing Address - Country:US
Mailing Address - Phone:509-444-8888
Mailing Address - Fax:
Practice Address - Street 1:1203 IDAHO ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-1940
Practice Address - Country:US
Practice Address - Phone:509-444-8888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-23
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-9211101YM0800X
ID6366101Y00000X
WA60022726101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60022726OtherSTATE LICENSE