Healthcare Provider Details

I. General information

NPI: 1821695305
Provider Name (Legal Business Name): ZACHARY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2020
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14058 MEMORIAL DR
HOUSTON TX
77079-6848
US

IV. Provider business mailing address

935 WAX MYRTLE LN
HOUSTON TX
77079-3772
US

V. Phone/Fax

Practice location:
  • Phone: 281-752-0403
  • Fax:
Mailing address:
  • Phone: 832-622-2257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-20-134331
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: