Provider Demographics
NPI:1760141501
Name:SMITH, TRAYLON GORDON
Entity Type:Individual
Prefix:
First Name:TRAYLON
Middle Name:GORDON
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 1:1540 E MAIN ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:OH
Mailing Address - Zip Code:43130-3405
Mailing Address - Country:US
Mailing Address - Phone:740-212-8137
Mailing Address - Fax:740-212-8702
Practice Address - Street 1:1540 E MAIN ST UNIT B
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:OH
Practice Address - Zip Code:43130-3405
Practice Address - Country:US
Practice Address - Phone:740-212-8137
Practice Address - Fax:740-212-8702
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-09
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator