Provider Demographics
NPI:1114273570
Name:SMITH, TAWANNA JEAN
Entity Type:Individual
Prefix:MRS
First Name:TAWANNA
Middle Name:JEAN
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 1:743 W 99TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-4605
Mailing Address - Country:US
Mailing Address - Phone:323-779-2296
Mailing Address - Fax:323-756-4135
Practice Address - Street 1:8220 S SAN PEDRO ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3030
Practice Address - Country:US
Practice Address - Phone:323-778-0488
Practice Address - Fax:323-778-0485
Is Sole Proprietor?:No
Enumeration Date:2012-08-02
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No104100000XBehavioral Health & Social Service ProvidersSocial Worker