Provider Demographics
NPI:1194442194
Name:SMART, TIFANEE A
Entity type:Individual
Prefix:
First Name:TIFANEE
Middle Name:A
Last Name:SMART
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 1:12-243 W POHAKUPELE LOOP
Mailing Address - Street 2:
Mailing Address - City:PAHOA
Mailing Address - State:HI
Mailing Address - Zip Code:96778-7863
Mailing Address - Country:US
Mailing Address - Phone:808-825-0616
Mailing Address - Fax:
Practice Address - Street 1:16-565 KEAAU PAHOA RD
Practice Address - Street 2:
Practice Address - City:KEAAU
Practice Address - State:HI
Practice Address - Zip Code:96749-8113
Practice Address - Country:US
Practice Address - Phone:808-313-4862
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIBACB527323106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI20315536Medicaid