MEDICARE: ALEXIS SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1215532247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS SMITH

Provider Business Mailing Address
First Line	:	900 DILWORTH ST APT E7
Second Line	:
City	:	SAINT MARYS
State	:	GA
Zip	:	31558-8692
Country	:	US
Telephone Number	:	321-684-9880
Fax Number	:

Provider Business Practice Location Address
First Line	:	5915 CEDAR HILLS BLVD
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-5119
Country	:	US
Telephone Number	:	904-503-0131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	11/30/2020

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