Provider Demographics
NPI:1467169268
Name:SMITH, MICA SKYLAR
Entity Type:Individual
Prefix:
First Name:MICA
Middle Name:SKYLAR
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BRIANA
Other - Middle Name:SYMONNE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4721 S CLIFF AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-6969
Mailing Address - Country:US
Mailing Address - Phone:816-608-1956
Mailing Address - Fax:800-687-5070
Practice Address - Street 1:123 E GAY ST STE A1
Practice Address - Street 2:
Practice Address - City:WARRENSBURG
Practice Address - State:MO
Practice Address - Zip Code:64093-1845
Practice Address - Country:US
Practice Address - Phone:660-864-0016
Practice Address - Fax:800-687-5070
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician