=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083002703
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | S.M.I.L.E. PSYCHOLOGY AND ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/05/2015
-----------------------------------------------------
Last Update Date | 01/02/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3831 TYRONE BLVD N STE 201E
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33709-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-569-6305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3831 TYRONE BLVD N STE 201E
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33709-4114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-569-6305
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/ CLINICAL PSYCHOTHERAPIST
-----------------------------------------------------
Name | DR. CARLEAH G EAST
-----------------------------------------------------
Credential | PHD
-----------------------------------------------------
Telephone | 727-569-6305
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | MH10595
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------