Provider Demographics
NPI:1194511352
Name:SMITH, SHANELL BRIANA
Entity type:Individual
Prefix:
First Name:SHANELL
Middle Name:BRIANA
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 SASSAFRAS ST
Mailing Address - Street 2:
Mailing Address - City:BROWNS MILLS
Mailing Address - State:NJ
Mailing Address - Zip Code:08015-1319
Mailing Address - Country:US
Mailing Address - Phone:609-332-1896
Mailing Address - Fax:
Practice Address - Street 1:110 CHURCH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-2201
Practice Address - Country:US
Practice Address - Phone:267-807-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRBT-23-297207106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician