Healthcare Provider Details

I. General information

NPI: 1083542542
Provider Name (Legal Business Name): SADE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 TRADE CENTER DR
EVANS GA
30809-6167
US

IV. Provider business mailing address

2148 WILLHAVEN DR
AUGUSTA GA
30909-0652
US

V. Phone/Fax

Practice location:
  • Phone: 706-723-8458
  • Fax: 718-865-5165
Mailing address:
  • Phone: 718-215-5311
  • Fax: 718-865-5165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: