Provider Demographics
NPI:1033769047
Name:SMITH, ANGILENE DAWN
Entity Type:Individual
Prefix:
First Name:ANGILENE
Middle Name:DAWN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGILENE
Other - Middle Name:DAWN
Other - Last Name:REARDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5716 N A ST
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-7206
Mailing Address - Country:US
Mailing Address - Phone:509-723-8460
Mailing Address - Fax:
Practice Address - Street 1:157 S HOWARD ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99201-4422
Practice Address - Country:US
Practice Address - Phone:800-781-5536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARBT-19-96962106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician