Provider Demographics
NPI:1144671884
Name:SMITH, DEREK JAMES (PHD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2853 E BENT TREE LN
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:ID
Mailing Address - Zip Code:83833-8674
Mailing Address - Country:US
Mailing Address - Phone:208-755-7393
Mailing Address - Fax:
Practice Address - Street 1:2853 E BENT TREE LN
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:ID
Practice Address - Zip Code:83833-8674
Practice Address - Country:US
Practice Address - Phone:208-755-7393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-23
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY-203364103T00000X
UT11022713-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist