Provider Demographics
NPI:1427323559
Name:SMITH, TAVARES DE'ANDREW
Entity type:Individual
Prefix:MR
First Name:TAVARES
Middle Name:DE'ANDREW
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 TAMERACK AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106-1418
Mailing Address - Country:US
Mailing Address - Phone:702-742-3561
Mailing Address - Fax:
Practice Address - Street 1:1100 TAMERACK AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-1418
Practice Address - Country:US
Practice Address - Phone:702-742-3561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-22
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst