Provider Demographics
NPI:1811663495
Name:SMITH, TYRA (RBT)
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:
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 1:2 VILLAGE SQ STE 210
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21210-1624
Mailing Address - Country:US
Mailing Address - Phone:937-847-8750
Mailing Address - Fax:
Practice Address - Street 1:2570 TECHNICAL DR
Practice Address - Street 2:
Practice Address - City:MIAMISBURG
Practice Address - State:OH
Practice Address - Zip Code:45342-6107
Practice Address - Country:US
Practice Address - Phone:937-847-8750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-23
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRBT-21-177558106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician