Provider Demographics
NPI:1932565587
Name:SMITH, KIRSTIE (BCBA)
Entity type:Individual
Prefix:MRS
First Name:KIRSTIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:KIRSTIE
Other - Middle Name:DANIELLE
Other - Last Name:TOLLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4534 BRUSHY CREEK CV
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-4057
Mailing Address - Country:US
Mailing Address - Phone:870-784-1421
Mailing Address - Fax:
Practice Address - Street 1:3310 S BROADWAY AVE STE 100A
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-7818
Practice Address - Country:US
Practice Address - Phone:903-991-8048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8986103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR211271721Medicaid