Provider Demographics
NPI:1730833963
Name:SMITH, LYNETTE WEEKS (HCBS PROVIDER)
Entity type:Individual
Prefix:
First Name:LYNETTE
Middle Name:WEEKS
Last Name:SMITH
Suffix:
Gender:F
Credentials:HCBS PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 374
Mailing Address - Street 2:
Mailing Address - City:MINNEOLA
Mailing Address - State:FL
Mailing Address - Zip Code:34755-0374
Mailing Address - Country:US
Mailing Address - Phone:352-346-4630
Mailing Address - Fax:407-347-7152
Practice Address - Street 1:3280 WHITE BLOSSOM LN
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-6246
Practice Address - Country:US
Practice Address - Phone:352-346-4630
Practice Address - Fax:407-347-7152
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL691446296106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL691446296Medicaid