Provider Demographics
NPI:1407552268
Name:SMITH, MACK STEVENSON (RBT)
Entity Type:Individual
Prefix:
First Name:MACK
Middle Name:STEVENSON
Last Name:SMITH
Suffix:
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 639561
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-9561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3744 W CHESTER PIKE
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3224
Practice Address - Country:US
Practice Address - Phone:610-863-7476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-03
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician