Provider Demographics
NPI:1194209726
Name:SMITH, THEENDRA D
Entity Type:Individual
Prefix:
First Name:THEENDRA
Middle Name:D
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 1:2490 LEE BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-1255
Mailing Address - Country:US
Mailing Address - Phone:216-600-5194
Mailing Address - Fax:
Practice Address - Street 1:2490 LEE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118-1255
Practice Address - Country:US
Practice Address - Phone:216-600-5194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty