Provider Demographics
NPI:1861591851
Name:WAYLAND-SMITH, DOUGLAS (PHD)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:
Last Name:WAYLAND-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 1:31 PORTER ST
Mailing Address - Street 2:PO BOX 800
Mailing Address - City:LAKEVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06039-1214
Mailing Address - Country:US
Mailing Address - Phone:860-435-9292
Mailing Address - Fax:
Practice Address - Street 1:31 PORTER ST
Practice Address - Street 2:POST OFFICE BOX 800
Practice Address - City:LAKEVILLE
Practice Address - State:CT
Practice Address - Zip Code:06039-1214
Practice Address - Country:US
Practice Address - Phone:860-435-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2008-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002476103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist