Provider Demographics
NPI:1568274850
Name:SMITH, MARKESHA ANTOINETTE
Entity type:Individual
Prefix:
First Name:MARKESHA
Middle Name:ANTOINETTE
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 1:4000 BUCKS RUN RD UNIT 102
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40219-3324
Mailing Address - Country:US
Mailing Address - Phone:502-919-1312
Mailing Address - Fax:
Practice Address - Street 1:4000 BUCKS RUN RD UNIT 102
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3324
Practice Address - Country:US
Practice Address - Phone:502-919-1312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-23
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYS05-294-117106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician