Provider Demographics
NPI:1477050516
Name:SMITH, ROBERT STANLEY (BCBA, LABA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:STANLEY
Last Name:SMITH
Suffix:
Gender:M
Credentials:BCBA, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DEERFIELD LN
Mailing Address - Street 2:
Mailing Address - City:EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02642-2250
Mailing Address - Country:US
Mailing Address - Phone:617-471-5497
Mailing Address - Fax:
Practice Address - Street 1:20 DEERFIELD LN
Practice Address - Street 2:
Practice Address - City:EASTHAM
Practice Address - State:MA
Practice Address - Zip Code:02642-2250
Practice Address - Country:US
Practice Address - Phone:617-471-5497
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty