Healthcare Provider Details

I. General information

NPI: 1831721273
Provider Name (Legal Business Name): TABITHA CHARLENE SMITH LPN, CDCA, QBHS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2020
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 ODNR MOHICAN 51
PERRYSVILLE OH
44864-9407
US

IV. Provider business mailing address

213 E CHESTNUT ST
MOUNT VERNON OH
43050-3404
US

V. Phone/Fax

Practice location:
  • Phone: 419-994-0300
  • Fax:
Mailing address:
  • Phone: 740-326-9255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA178300
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.111823.MEDS
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: