Healthcare Provider Details

I. General information

NPI: 1295447373
Provider Name (Legal Business Name): MISS TAMARA ANTONETTE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TAMARA ANTONETTE SMITH

II. Dates (important events)

Enumeration Date: 12/20/2022
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 THOMAS SHILLING CT
UPPERCO MD
21155-9334
US

IV. Provider business mailing address

9 HARTWICK DR APT 124
SKILLMAN NJ
08558-1835
US

V. Phone/Fax

Practice location:
  • Phone: 410-720-9337
  • Fax:
Mailing address:
  • Phone: 848-702-9440
  • 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 Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: