Provider Demographics
NPI:1275016321
Name:SMITH, BERTHA L
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:L
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 1:842 MARGARET PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4521
Mailing Address - Country:US
Mailing Address - Phone:318-675-0406
Mailing Address - Fax:318-675-0408
Practice Address - Street 1:842 MARGARET PL
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4521
Practice Address - Country:US
Practice Address - Phone:318-675-0406
Practice Address - Fax:318-675-0408
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1568534857OtherNPI