MEDICARE: MRS. FREDASHARRON 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	101YA0400X	Addiction (Substance Use Disorder) Counselor	17570-130	WI

General Provider Information

NPI Number	:	1336685650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. FREDASHARRON SMITH

Provider Business Mailing Address
First Line	:	3853 N 55TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2209
Country	:	US
Telephone Number	:	414-366-9220
Fax Number	:

Provider Business Practice Location Address
First Line	:	3853 N 55TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53216-2209
Country	:	US
Telephone Number	:	414-366-9220
Fax Number	:

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

Provider Enumeration Date	:	01/10/2017
Last Update Date	:	01/11/2017

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