Provider Demographics
NPI:1639858020
Name:SMITH, MARTIESA
Entity Type:Individual
Prefix:
First Name:MARTIESA
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:PO BOX 268
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77404-0268
Mailing Address - Country:US
Mailing Address - Phone:979-313-8148
Mailing Address - Fax:
Practice Address - Street 1:617 E PLUM ST
Practice Address - Street 2:
Practice Address - City:ANGLETON
Practice Address - State:TX
Practice Address - Zip Code:77515-5043
Practice Address - Country:US
Practice Address - Phone:979-479-6193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-13
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator