MEDICARE: EBONY 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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1912693235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EBONY SMITH

Provider Business Mailing Address
First Line	:	12308 COUGAR LN SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87123-3527
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12308 COUGAR LN SE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87123-3527
Country	:	US
Telephone Number	:	505-365-9012
Fax Number	:

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

Provider Enumeration Date	:	04/11/2023
Last Update Date	:	04/11/2023

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Directions to “ EBONY SMITH ” Practice Location

Language	Start Address	Practice Location

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