Healthcare Provider Details

I. General information

NPI: 1326511593
Provider Name (Legal Business Name): SMITH BEHAVIORAL HEALTH, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/09/2019
Last Update Date: 01/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 W 1ST ST UNIT 120
MESA AZ
85201-6554
US

IV. Provider business mailing address

225 W 1ST ST UNIT 120
MESA AZ
85201-6554
US

V. Phone/Fax

Practice location:
  • Phone: 602-743-8157
  • Fax:
Mailing address:
  • Phone: 602-743-8157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MARK IVAN SMITH
Title or Position: PRESIDENT
Credential:
Phone: 602-743-8157