Provider Demographics
NPI:1790491652
Name:SMITH, IVANA MICHELE
Entity Type:Individual
Prefix:MISS
First Name:IVANA
Middle Name:MICHELE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:IVANA
Other - Middle Name:MICHELE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REYNOLDS
Mailing Address - Street 1:1025 AE ST APT H106
Mailing Address - Street 2:
Mailing Address - City:KAPOLEI
Mailing Address - State:HI
Mailing Address - Zip Code:96707-4579
Mailing Address - Country:US
Mailing Address - Phone:808-375-9846
Mailing Address - Fax:
Practice Address - Street 1:1025 AE ST APT H106
Practice Address - Street 2:
Practice Address - City:KAPOLEI
Practice Address - State:HI
Practice Address - Zip Code:96707-4579
Practice Address - Country:US
Practice Address - Phone:808-375-9846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician