Basic Information
| Provider Information | |||||||||
| NPI: | 1285116343 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DUSTIN | ||||||||
| MiddleName: | ERIC | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3170 W CENTRAL AVE STE B | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436062945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5673167253 | ||||||||
| FaxNumber: | 5673167232 | ||||||||
| Practice Location | |||||||||
| Address1: | 3170 W CENTRAL AVE STE B | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 436062945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5673167253 | ||||||||
| FaxNumber: | 5673167232 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2018 | ||||||||
| LastUpdateDate: | 09/05/2018 | ||||||||
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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 | 104100000X | S1200800 | OH | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.