Basic Information
| Provider Information | |||||||||
| NPI: | 1306976527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOE | ||||||||
| MiddleName: | WILLIE | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5128 N 56TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532184214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4145870508 | ||||||||
| FaxNumber: | 4144630873 | ||||||||
| Practice Location | |||||||||
| Address1: | 6040 W LISBON AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532102116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144479890 | ||||||||
| FaxNumber: | 4144479891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 101Y00000X | WI | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.