Healthcare Provider Details

I. General information

NPI: 1699405324
Provider Name (Legal Business Name): LA-TISHA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FLATBUSH AVE # 1
BROOKLYN NY
11217-2812
US

IV. Provider business mailing address

300 FLATBUSH AVE
BROOKLYN NY
11217-2812
US

V. Phone/Fax

Practice location:
  • Phone: 718-622-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: