Provider Demographics
NPI:1083170641
Name:SMITH, MYLENA DASHAUN
Entity Type:Individual
Prefix:
First Name:MYLENA
Middle Name:DASHAUN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2812 N. NORWALK ST BLDG 14
Mailing Address - Street 2:STE 127 & 128
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2812 N. NORWALK ST BLDG. 14
Practice Address - Street 2:STE 127 & 128
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85215
Practice Address - Country:US
Practice Address - Phone:213-305-5329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic