Provider Demographics
NPI:1093413775
Name:SMITH, FREDDIE
Entity Type:Individual
Prefix:
First Name:FREDDIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8101 W LAMAR RD APT 44
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85303-2721
Mailing Address - Country:US
Mailing Address - Phone:602-425-3188
Mailing Address - Fax:
Practice Address - Street 1:8101 W LAMAR RD APT 44
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85303-2721
Practice Address - Country:US
Practice Address - Phone:602-425-3188
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-21
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171W00000XOther Service ProvidersContractorGroup - Single Specialty
No251B00000XAgenciesCase Management