Provider Demographics
NPI:1275243230
Name:SMITH, ADDIE
Entity Type:Individual
Prefix:
First Name:ADDIE
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 1:185 MITTIE HADDOCK DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON
Mailing Address - State:NC
Mailing Address - Zip Code:28326-9379
Mailing Address - Country:US
Mailing Address - Phone:910-500-7783
Mailing Address - Fax:
Practice Address - Street 1:185 MITTIE HADDOCK DR
Practice Address - Street 2:
Practice Address - City:CAMERON
Practice Address - State:NC
Practice Address - Zip Code:28326-9379
Practice Address - Country:US
Practice Address - Phone:910-500-7783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000030558706106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician