Provider Demographics
NPI:1932342078
Name:SMITH, BERTHA E
Entity Type:Individual
Prefix:
First Name:BERTHA
Middle Name:E
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 1:569 BANKS RD
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-4602
Mailing Address - Country:US
Mailing Address - Phone:954-258-7060
Mailing Address - Fax:954-978-1960
Practice Address - Street 1:569 BANKS RD
Practice Address - Street 2:
Practice Address - City:MARGATE
Practice Address - State:FL
Practice Address - Zip Code:33063-4602
Practice Address - Country:US
Practice Address - Phone:954-258-7060
Practice Address - Fax:954-978-1960
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAPPLIED FORMedicaid