Provider Demographics
NPI:1497501373
Name:SMITH, ROBERT (CDCA)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 E HOME RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45503-2520
Mailing Address - Country:US
Mailing Address - Phone:937-390-8060
Mailing Address - Fax:
Practice Address - Street 1:2317 E HOME RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2520
Practice Address - Country:US
Practice Address - Phone:937-390-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.182464175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist