Provider Demographics
NPI:1548703341
Name:SMITH, LOREN MICHELLE (MA, BCBA)
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:LOREN
Other - Middle Name:MICHELLE
Other - Last Name:SIGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,BCBA
Mailing Address - Street 1:8382 BAYMEADOWS RD STE 9
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7436
Mailing Address - Country:US
Mailing Address - Phone:904-755-0646
Mailing Address - Fax:
Practice Address - Street 1:8382 BAYMEADOWS RD STE 9
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7436
Practice Address - Country:US
Practice Address - Phone:904-755-0646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2024-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
FL1-18-33781103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician