Provider Demographics
NPI:1992382899
Name:SMITH, SHELLY REGINE
Entity Type:Individual
Prefix:MISS
First Name:SHELLY
Middle Name:REGINE
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 1:77 E WOODBURY DR STE 110
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415-2853
Mailing Address - Country:US
Mailing Address - Phone:937-569-8552
Mailing Address - Fax:
Practice Address - Street 1:77 E WOODBURY DR STE 110
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2853
Practice Address - Country:US
Practice Address - Phone:937-569-8552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1992382899Medicaid