Provider Demographics
NPI:1912446345
Name:SMITH, TYFAINE (BCBA, LBA)
Entity Type:Individual
Prefix:
First Name:TYFAINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 N. BURLESON BLVD
Mailing Address - Street 2:SUITE 107-344
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028
Mailing Address - Country:US
Mailing Address - Phone:682-214-7628
Mailing Address - Fax:818-758-8015
Practice Address - Street 1:1169 N. BURLESON BLVD
Practice Address - Street 2:SUITE 107-344
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028
Practice Address - Country:US
Practice Address - Phone:682-214-7628
Practice Address - Fax:818-758-8015
Is Sole Proprietor?:No
Enumeration Date:2017-02-17
Last Update Date:2020-02-06
Deactivation Date:2017-12-21
Deactivation Code:
Reactivation Date:2020-02-06
Provider Licenses
StateLicense IDTaxonomies
TX1-16-24365103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1-16-24365OtherBACB