Provider Demographics
NPI:1538590005
Name:RANDOLPH SMITH, TONYA
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:RANDOLPH 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 1:12227 W HADLEY ST
Mailing Address - Street 2:
Mailing Address - City:AVONDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85323-8434
Mailing Address - Country:US
Mailing Address - Phone:414-617-8549
Mailing Address - Fax:
Practice Address - Street 1:12227 W HADLEY ST
Practice Address - Street 2:
Practice Address - City:AVONDALE
Practice Address - State:AZ
Practice Address - Zip Code:85323-8434
Practice Address - Country:US
Practice Address - Phone:414-617-8549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-09
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3467447385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child