Provider Demographics
NPI:1891361499
Name:SMITH, COLLIN THOMAS
Entity Type:Individual
Prefix:
First Name:COLLIN
Middle Name:THOMAS
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 1:935 WAX MYRTLE LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-3772
Mailing Address - Country:US
Mailing Address - Phone:713-205-2375
Mailing Address - Fax:
Practice Address - Street 1:14058 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-6848
Practice Address - Country:US
Practice Address - Phone:281-752-0403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX42535167106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician