Provider Demographics
NPI:1811520927
Name:SMITH, BEVANNIE (MA,BCBA)
Entity type:Individual
Prefix:
First Name:BEVANNIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA,BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5811 BLUEBERRY CT
Mailing Address - Street 2:
Mailing Address - City:LAUDERHILL
Mailing Address - State:FL
Mailing Address - Zip Code:33313-3079
Mailing Address - Country:US
Mailing Address - Phone:954-770-7818
Mailing Address - Fax:
Practice Address - Street 1:1239 E NEWPORT CENTER DR STE 101
Practice Address - Street 2:
Practice Address - City:DEERFIELD BEACH
Practice Address - State:FL
Practice Address - Zip Code:33442-7711
Practice Address - Country:US
Practice Address - Phone:754-444-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-19-39965103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst