Provider Demographics
NPI:1013367705
Name:SMITH STREET LLC
Entity Type:Organization
Organization Name:SMITH STREET LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:REHNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:970-484-8250
Mailing Address - Street 1:310 SMITH ST
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80524-2940
Mailing Address - Country:US
Mailing Address - Phone:970-484-8250
Mailing Address - Fax:
Practice Address - Street 1:308 SMITH ST.
Practice Address - Street 2:
Practice Address - City:FORT COLLINS
Practice Address - State:CO
Practice Address - Zip Code:80524
Practice Address - Country:US
Practice Address - Phone:970-484-8250
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-14
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO96702834251C00000X
373H00000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty