Provider Demographics
NPI:1376993741
Name:SMITH, ALTHEA
Entity Type:Individual
Prefix:
First Name:ALTHEA
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 1:4387 NW 42ND TER
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-3859
Mailing Address - Country:US
Mailing Address - Phone:954-292-3596
Mailing Address - Fax:954-729-2491
Practice Address - Street 1:4387 NW 42ND TER
Practice Address - Street 2:
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-3859
Practice Address - Country:US
Practice Address - Phone:954-292-3596
Practice Address - Fax:954-729-2491
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-16
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12624251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL12624Medicaid