Provider Demographics
NPI:1659047132
Name:SMITH, ANDREA (MA BCBA)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA BCBA
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 800341
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-0007
Mailing Address - Country:US
Mailing Address - Phone:706-298-6381
Mailing Address - Fax:
Practice Address - Street 1:316 N LEWIS ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2740
Practice Address - Country:US
Practice Address - Phone:706-298-6381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1-21-52517103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst