Provider Demographics
NPI:1407439250
Name:SMITH, NATHANIEL A
Entity Type:Individual
Prefix:MR
First Name:NATHANIEL
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 NE 9TH ST
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4409
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5216 SW 90TH TER
Practice Address - Street 2:
Practice Address - City:COOPER CITY
Practice Address - State:FL
Practice Address - Zip Code:33328-5013
Practice Address - Country:US
Practice Address - Phone:561-431-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104850100Medicaid