Provider Demographics
NPI:1669866067
Name:COLLINS-SMITH, PEBBLES
Entity Type:Individual
Prefix:MS
First Name:PEBBLES
Middle Name:
Last Name:COLLINS-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 1:12214 SW 203RD TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33177-5260
Mailing Address - Country:US
Mailing Address - Phone:305-218-4429
Mailing Address - Fax:305-218-4429
Practice Address - Street 1:12214 SW 203RD TER
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33177-5260
Practice Address - Country:US
Practice Address - Phone:305-218-4429
Practice Address - Fax:305-218-4429
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-24
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL472640728Medicaid