Provider Demographics
NPI:1639777196
Name:SMITH, NINJA
Entity Type:Individual
Prefix:
First Name:NINJA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 BRANDYWINE DR APT 216
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-5261
Mailing Address - Country:US
Mailing Address - Phone:862-218-9305
Mailing Address - Fax:
Practice Address - Street 1:3801 BRANDYWINE DR APT 216
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5261
Practice Address - Country:US
Practice Address - Phone:862-218-9305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-15
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X
TXRBT-18-61267106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst