Provider Demographics
NPI:1871246132
Name:SMITH, JUNIOR (BA)
Entity Type:Individual
Prefix:
First Name:JUNIOR
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 SW 16TH AVE BLDG B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1153
Mailing Address - Country:US
Mailing Address - Phone:786-590-8000
Mailing Address - Fax:
Practice Address - Street 1:1701 SW 16TH AVE BLDG B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1153
Practice Address - Country:US
Practice Address - Phone:786-590-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL104100000X104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker