Provider Demographics
NPI:1225746498
Name:SMITH, NINA
Entity Type:Individual
Prefix:
First Name:NINA
Middle Name:
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 1:500A SAINT VINCENT ST
Mailing Address - Street 2:
Mailing Address - City:DONALDSONVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70346-3412
Mailing Address - Country:US
Mailing Address - Phone:225-910-0500
Mailing Address - Fax:
Practice Address - Street 1:17505 OLD JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:PRAIRIEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70769-3930
Practice Address - Country:US
Practice Address - Phone:985-500-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician