Provider Demographics
NPI:1881217099
Name:SMITH, MIKEL
Entity Type:Individual
Prefix:
First Name:MIKEL
Middle Name:
Last Name: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 1:6455 S SHORE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5525
Mailing Address - Country:US
Mailing Address - Phone:855-782-7822
Mailing Address - Fax:
Practice Address - Street 1:6455 S SHORE BLVD STE 400
Practice Address - Street 2:
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-5525
Practice Address - Country:US
Practice Address - Phone:855-782-7822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-21
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIRBT-20-111352106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician