Provider Demographics
NPI:1154053288
Name:SMITH, SHEENA
Entity type:Individual
Prefix:
First Name:SHEENA
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 1:104 SANFORD PL
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3316
Mailing Address - Country:US
Mailing Address - Phone:917-640-9075
Mailing Address - Fax:
Practice Address - Street 1:78 1/2 9TH AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1518
Practice Address - Country:US
Practice Address - Phone:917-640-9075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-28
Last Update Date:2024-04-24
Deactivation Date:2024-03-21
Deactivation Code:
Reactivation Date:2024-04-24
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00690300101YM0800X
NJ37PC01019000101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ300838743Medicaid