Provider Demographics
NPI:1053392910
Name:SMILEY, JUSTIN FORD (MSW)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:FORD
Last Name:SMILEY
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 388
Mailing Address - Street 2:
Mailing Address - City:PLUMMER
Mailing Address - State:ID
Mailing Address - Zip Code:83851-0388
Mailing Address - Country:US
Mailing Address - Phone:208-686-1449
Mailing Address - Fax:208-686-5813
Practice Address - Street 1:1115 B STREET
Practice Address - Street 2:
Practice Address - City:PLUMMER
Practice Address - State:ID
Practice Address - Zip Code:83851
Practice Address - Country:US
Practice Address - Phone:208-686-1449
Practice Address - Fax:208-686-5813
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSOCIAL WORK 24211104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker