Healthcare Provider Details

I. General information

NPI: 1902509433
Provider Name (Legal Business Name): TIEESHA TAMAR SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 06/08/2023
Certification Date: 06/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3219 75TH AVE APT 204
LANDOVER MD
20785-1918
US

IV. Provider business mailing address

3219 75TH AVE APT 204
LANDOVER MD
20785-1918
US

V. Phone/Fax

Practice location:
  • Phone: 301-919-2439
  • Fax:
Mailing address:
  • Phone: 301-919-2439
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: