Provider Demographics
NPI:1205322732
Name:SMITH, ANDREW WAYNE (LCDC II)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:WAYNE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCDC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 DENNISON AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43215-1315
Mailing Address - Country:US
Mailing Address - Phone:614-291-4691
Mailing Address - Fax:614-291-6232
Practice Address - Street 1:825 DENNISON AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43215-1315
Practice Address - Country:US
Practice Address - Phone:614-291-4691
Practice Address - Fax:614-291-6232
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH081059101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)