Healthcare Provider Details

I. General information

NPI: 1275053134
Provider Name (Legal Business Name): CHARLES SMITH RBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2017
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 S MAIN ST STE 240
DAYTON OH
45402-2070
US

IV. Provider business mailing address

2000 NOBLE DR
WOOSTER OH
44691-5353
US

V. Phone/Fax

Practice location:
  • Phone: 614-842-7649
  • Fax: 937-606-3132
Mailing address:
  • Phone: 937-847-3302
  • Fax: 330-264-3879

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: