Healthcare Provider Details

I. General information

NPI: 1457896854
Provider Name (Legal Business Name): EMACULETE SMITH CDCA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2016
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4977 NORTHCUTT PL
DAYTON OH
45414-3839
US

IV. Provider business mailing address

1007 N UNION ST
LIMA OH
45801-2942
US

V. Phone/Fax

Practice location:
  • Phone: 937-387-6395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA161690
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: