Provider Demographics
NPI:1902931132
Name:SMOTHERS, DAVID BRIAN (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:BRIAN
Last Name:SMOTHERS
Suffix:
Gender:M
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9120 W HAMPTON AVE STE 212
Mailing Address - Street 2:WSPP
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-4960
Mailing Address - Country:US
Mailing Address - Phone:414-464-9777
Mailing Address - Fax:
Practice Address - Street 1:10425 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2416
Practice Address - Country:US
Practice Address - Phone:414-367-9413
Practice Address - Fax:414-358-5590
Is Sole Proprietor?:No
Enumeration Date:2007-02-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3865-125101YP2500X
WI2973-57103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIMA 43599400Medicaid