MEDICARE: SHANNON DEVAUGHN 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	000332976	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326669888
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON DEVAUGHN SMITH

Provider Business Mailing Address
First Line	:	17400 NORTHWOOD AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-2210
Country	:	US
Telephone Number	:	216-403-8640
Fax Number	:

Provider Business Practice Location Address
First Line	:	17400 NORTHWOOD AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-2210
Country	:	US
Telephone Number	:	216-403-8640
Fax Number	:

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

Provider Enumeration Date	:	05/06/2020
Last Update Date	:	05/06/2020

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