Healthcare Provider Details

I. General information

NPI: 1174369987
Provider Name (Legal Business Name): REBECCA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2024
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 DOLPHIN FLEET CIR APT 208
SOUTH DAYTONA FL
32119-9041
US

IV. Provider business mailing address

390 RIVER STREET
SPRINGFIELD VT
05156-2226
US

V. Phone/Fax

Practice location:
  • Phone: 386-393-7044
  • Fax:
Mailing address:
  • Phone: 802-886-4500
  • Fax: 802-886-4520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: