Healthcare Provider Details

I. General information

NPI: 1407656705
Provider Name (Legal Business Name): QUINCY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3680 N RANCHO DR
LAS VEGAS NV
89130-3180
US

IV. Provider business mailing address

624 BURSTING SUN AVE
NORTH LAS VEGAS NV
89032-8240
US

V. Phone/Fax

Practice location:
  • Phone: 702-646-5437
  • Fax:
Mailing address:
  • Phone: 510-565-4211
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: