Provider Demographics
NPI:1124559364
Name:SMITH, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:
Other - Last Name:BAXT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:34119 ALAMEDA DR
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:FL
Mailing Address - Zip Code:32776-6955
Mailing Address - Country:US
Mailing Address - Phone:407-949-8048
Mailing Address - Fax:
Practice Address - Street 1:34119 ALAMEDA DR
Practice Address - Street 2:
Practice Address - City:SORRENTO
Practice Address - State:FL
Practice Address - Zip Code:32776-6955
Practice Address - Country:US
Practice Address - Phone:407-949-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician