=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619607868
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CANYON SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2022
-----------------------------------------------------
Last Update Date | 06/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29543 AUTUMN COPPER
-----------------------------------------------------
City | BULVERDE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78163-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-749-9033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29543 AUTUMN COPPER
-----------------------------------------------------
City | BULVERDE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 78163-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 575-749-9033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number | BACB794096
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number | 12476576
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------