Provider Demographics
NPI:1518584168
Name:SMITH, SHANEKQUA RENA
Entity type:Individual
Prefix:
First Name:SHANEKQUA
Middle Name:RENA
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 1:7108 S KANNER HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34997-7462
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:501 W BROADWAY STE 800
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-3546
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-30
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician