Provider Demographics
NPI:1205442589
Name:SMITH, JUSTINE BREEDON (RBT)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:BREEDON
Last Name:SMITH
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 N KINGS RD APT 5
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2189
Mailing Address - Country:US
Mailing Address - Phone:701-306-5070
Mailing Address - Fax:
Practice Address - Street 1:600 N KINGS RD APT 5
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-2189
Practice Address - Country:US
Practice Address - Phone:701-306-5070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-22
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-20-110200106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician