Provider Demographics
NPI:1669972253
Name:SMITH, KHADIJAH RENEE
Entity type:Individual
Prefix:
First Name:KHADIJAH
Middle Name:RENEE
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 1:9449 BRIAR FOREST DR APT 2705
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77063-1044
Mailing Address - Country:US
Mailing Address - Phone:662-739-1988
Mailing Address - Fax:
Practice Address - Street 1:9449 BRIAR FOREST DR APT 2705
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77063-1044
Practice Address - Country:US
Practice Address - Phone:662-739-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1848676106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1848676OtherBEHAVIOR TECHNICIAN