MEDICARE: ELLIS SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	L-782	LA

General Provider Information

NPI Number	:	1114709920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLIS SMITH

Provider Business Mailing Address
First Line	:	1301 SAINT MARY ST
Second Line	:
City	:	THIBODAUX
State	:	LA
Zip	:	70301-6527
Country	:	US
Telephone Number	:	985-446-6833
Fax Number	:	985-446-6835

Provider Business Practice Location Address
First Line	:	1522 CHIPPEWA ST
Second Line	:
City	:	NEW ORLEANS
State	:	LA
Zip	:	70130-4513
Country	:	US
Telephone Number	:	985-446-6833
Fax Number	:	985-446-6835

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2023
Last Update Date	:	10/17/2023

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Directions to “ ELLIS SMITH ” Practice Location

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