Healthcare Provider Details

I. General information

NPI: 1972215135
Provider Name (Legal Business Name): SENIQA TRIXINE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 TALBOT AVE
DORCHESTER MA
02124-3717
US

IV. Provider business mailing address

520 DUDLEY ST
BOSTON MA
02119-2769
US

V. Phone/Fax

Practice location:
  • Phone: 334-349-3635
  • Fax:
Mailing address:
  • Phone: 334-349-3635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: