Basic Information
Provider Information
NPI: 1003140286
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: DALE
MiddleName: JAMES
NamePrefix: MR.
NameSuffix:  
Credential: L.I.S.W.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1301 N HIGH ST
Address2:  
City: COLUMBUS
State: OH
PostalCode: 432012460
CountryCode: US
TelephoneNumber: 6142996600
FaxNumber: 6142982224
Practice Location
Address1: 1301 N HIGH ST
Address2:  
City: COLUMBUS
State: OH
PostalCode: 432012460
CountryCode: US
TelephoneNumber: 6142996600
FaxNumber: 6142982224
Other Information
ProviderEnumerationDate: 09/22/2009
LastUpdateDate: 09/22/2009
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1041C0700XI.0900238OHY Behavioral Health & Social Service ProvidersSocial WorkerClinical

No ID Information.


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