Provider Demographics
NPI:1316635147
Name:SMITH, MICHAELA (BCBA, LBA)
Entity type:Individual
Prefix:
First Name:MICHAELA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA, LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2713 CRATER LAKE LN
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76210-3378
Mailing Address - Country:US
Mailing Address - Phone:214-609-5974
Mailing Address - Fax:
Practice Address - Street 1:2405 N ANKENY BLVD
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-4723
Practice Address - Country:US
Practice Address - Phone:515-446-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-28
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5812103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst