Provider Demographics
NPI:1861147324
Name:SMITH, NICHOLAS DAVID WOLOSZYN (PHD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS DAVID
Middle Name:WOLOSZYN
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 1:2937 WINGLEWOOD CIR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5036
Mailing Address - Country:US
Mailing Address - Phone:724-599-4315
Mailing Address - Fax:
Practice Address - Street 1:501 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4630
Practice Address - Country:US
Practice Address - Phone:727-767-7451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-14
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY11240103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMYDVFOtherBLUE CROSS BLUE SHIELD
FL113855800Medicaid