Healthcare Provider Details

I. General information

NPI: 1821929761
Provider Name (Legal Business Name): TY SMITH RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1750 TREE BLVD STE 6
ST AUGUSTINE FL
32084-5719
US

IV. Provider business mailing address

99 BRADDOCK LN
PALM COAST FL
32137-8767
US

V. Phone/Fax

Practice location:
  • Phone: 904-206-7024
  • Fax:
Mailing address:
  • Phone: 386-302-7033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-540026
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: