Healthcare Provider Details

I. General information

NPI: 1316440308
Provider Name (Legal Business Name): MICAH JOVAN SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 E DESERT INN RD STE 130
LAS VEGAS NV
89121-3690
US

IV. Provider business mailing address

2755 E DESERT INN RD STE 130
LAS VEGAS NV
89121-3690
US

V. Phone/Fax

Practice location:
  • Phone: 702-490-9009
  • Fax: 866-737-6147
Mailing address:
  • Phone: 702-490-9009
  • Fax: 866-737-6147

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: