Provider Demographics
NPI:1891459186
Name:SMITH, ANGELIQUE L
Entity type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:L
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 1:1967 CAMINO DOS ANTONIOS
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507-3307
Mailing Address - Country:US
Mailing Address - Phone:505-780-9590
Mailing Address - Fax:
Practice Address - Street 1:1967 CAMINO DOS ANTONIOS
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507-3307
Practice Address - Country:US
Practice Address - Phone:505-780-9590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-24
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician