=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770347676
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRYSTINA JANAE SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/12/2024
-----------------------------------------------------
Last Update Date | 02/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4410 CLAIBORNE SQ E STE 233
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-2072
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-788-8033
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 WELLINGTON CIR
-----------------------------------------------------
City | SMITHFIELD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23430-6283
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-371-3384
-----------------------------------------------------
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 | RBT-20-144837
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------