Healthcare Provider Details

I. General information

NPI: 1073288288
Provider Name (Legal Business Name): MR. MALIKI DEANE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2021
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6320 PENN AVE S
RICHFIELD MN
55423-1139
US

IV. Provider business mailing address

6320 PENN AVE S
RICHFIELD MN
55423-1139
US

V. Phone/Fax

Practice location:
  • Phone: 612-677-2350
  • Fax:
Mailing address:
  • Phone: 612-677-2350
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2846530
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-178880
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: