Provider Demographics
NPI:1548887995
Name:SMITH, KATIE
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
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 1:2852 LODGE POLE CT
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-5213
Mailing Address - Country:US
Mailing Address - Phone:702-561-3408
Mailing Address - Fax:
Practice Address - Street 1:1175 W PECOS RD
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-5212
Practice Address - Country:US
Practice Address - Phone:702-561-3408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-01
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ85-1717824Medicaid