Provider Demographics
NPI:1336631985
Name:PETIT FRERE, SMANA
Entity Type:Individual
Prefix:
First Name:SMANA
Middle Name:
Last Name:PETIT FRERE
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 1:4323 NW 3RD TER
Mailing Address - Street 2:
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33064-2532
Mailing Address - Country:US
Mailing Address - Phone:954-708-5933
Mailing Address - Fax:
Practice Address - Street 1:4323 NW 3RD TER
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33064-2532
Practice Address - Country:US
Practice Address - Phone:954-708-5933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-30
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid