Healthcare Provider Details

I. General information

NPI: 1891387676
Provider Name (Legal Business Name): ANDREW SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2021
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11865 WEXFORD CLUB DR
ROSWELL GA
30075-1471
US

IV. Provider business mailing address

7013 SOMERSET CIR
ALPHARETTA GA
30004-3847
US

V. Phone/Fax

Practice location:
  • Phone: 925-752-2119
  • Fax:
Mailing address:
  • Phone: 678-448-6361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-23-66257
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: