Healthcare Provider Details

I. General information

NPI: 1770258311
Provider Name (Legal Business Name): SHANNA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2021
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

883 SEVEN OAKS BLVD STE 850
SMYRNA TN
37167-6691
US

IV. Provider business mailing address

300 INTERNATIONAL PKWY STE 300
LAKE MARY FL
32746-5000
US

V. Phone/Fax

Practice location:
  • Phone: 629-216-2007
  • Fax:
Mailing address:
  • Phone: 629-216-2007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-24-75008
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-192742
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: