Provider Demographics
NPI:1346518198
Name:SMITH, WILLIAM RANDALL (BCBA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:RANDALL
Last Name:SMITH
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 DAUGHERTY STREET
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:GA
Mailing Address - Zip Code:30728
Mailing Address - Country:US
Mailing Address - Phone:706-996-6604
Mailing Address - Fax:866-363-3758
Practice Address - Street 1:902 DAUGHERTY STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:GA
Practice Address - Zip Code:30728
Practice Address - Country:US
Practice Address - Phone:706-996-6604
Practice Address - Fax:866-286-4804
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-08
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-11-9558103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst