Healthcare Provider Details

I. General information

NPI: 1144714304
Provider Name (Legal Business Name): TERRELL BERNARD SMITH RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 05/15/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 ALLEN ST
MARTINEZ CA
94553
US

IV. Provider business mailing address

5982 RHODES RD
KENT OH
44240-8100
US

V. Phone/Fax

Practice location:
  • Phone: 925-995-3957
  • Fax:
Mailing address:
  • Phone: 330-673-1347
  • Fax: 330-678-3677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.488666
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number1144714304
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: