Provider Demographics
NPI:1558829465
Name:SMITH, SHEA E (RBT)
Entity Type:Individual
Prefix:MISS
First Name:SHEA
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3490 N PASEO DE SAN AGUSTIN
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6035
Mailing Address - Country:US
Mailing Address - Phone:855-462-3672
Mailing Address - Fax:
Practice Address - Street 1:3490 N PASEO DE SAN AGUSTIN
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6035
Practice Address - Country:US
Practice Address - Phone:855-462-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-10
Last Update Date:2019-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
WA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst