Provider Demographics
NPI:1518210483
Name:SMITH, CORETHA DENISE (CERTIFIED ADDICTION)
Entity Type:Individual
Prefix:MS
First Name:CORETHA
Middle Name:DENISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CERTIFIED ADDICTION
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 1465
Mailing Address - Street 2:136 SOUTH MAIN STREET
Mailing Address - City:BELLE GLADE
Mailing Address - State:FL
Mailing Address - Zip Code:33430
Mailing Address - Country:US
Mailing Address - Phone:561-996-0500
Mailing Address - Fax:561-992-8333
Practice Address - Street 1:136 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430
Practice Address - Country:US
Practice Address - Phone:561-996-0500
Practice Address - Fax:561-992-8333
Is Sole Proprietor?:No
Enumeration Date:2012-10-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5030101YA0400X
FL007101YA0400X
FL0025101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)