Basic Information
| Provider Information | |||||||||
| NPI: | 1184618647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DONALD | ||||||||
| MiddleName: | RAY | ||||||||
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| Credential: | M.ED., LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 METRO DR | ||||||||
| Address2: | SUITE B | ||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 651094408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736344591 | ||||||||
| FaxNumber: | 5736344792 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 N GARTH AVE | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652034103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734432204 | ||||||||
| FaxNumber: | 5738755851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2005 | ||||||||
| LastUpdateDate: | 07/13/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 2003019598 | MO | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 1467597872 | 01 | MO | JEFF CITY NPI | OTHER | 1649269622 | 01 | MO | GROUP BILLING NPI | OTHER |