=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548649759
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MONTANEISH RENEA SMITH RCSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2015
-----------------------------------------------------
Last Update Date | 01/25/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11924 FOREST HILL BLVD STE. 10A-243
-----------------------------------------------------
City | WELLINGTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33414-6256
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-357-8878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17841 PRADO BLVD
-----------------------------------------------------
City | LOXAHATCHEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-3648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-357-8878
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | ISW9539
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------