Provider Demographics
NPI:1619631322
Name:SMITH, EULYSES
Entity Type:Individual
Prefix:
First Name:EULYSES
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 PAN AMERICAN FWY NE APT 213
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87107-4765
Mailing Address - Country:US
Mailing Address - Phone:505-835-4733
Mailing Address - Fax:
Practice Address - Street 1:4330 PAN AMERICAN FWY NE APT 337
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87107-4734
Practice Address - Country:US
Practice Address - Phone:505-835-4733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-28
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM103K00000X103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst