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General NPI Number Information
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NPI Number | 1609245752
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Entity Type | Individual
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Provider Name | SHELLY SMITH
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Gender | Female
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Dates
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Enumeration Date | 09/18/2015
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Last Update Date | 09/18/2015
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Provider Practice Location Address
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Address Line | 6060 N WILDHORSE DR
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-3346
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Country | US
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Telephone | 760-644-3670
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Fax |
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Provider Business Mailing Address
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Address Line | 6060 N WILDHORSE DR
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City | PRESCOTT VALLEY
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State | AZ
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Zip | 86314-3346
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2055X
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Taxonomy Name | Child Mental Illness Respite Care
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License Number | BH4554
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License Number State | AZ
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