Provider Demographics
NPI:1316440308
Name:SMITH, MICAH JOVAN
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:JOVAN
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 1:2501 N GREEN VALLEY PKWY STE 116-118
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89014-0273
Mailing Address - Country:US
Mailing Address - Phone:702-605-2766
Mailing Address - Fax:
Practice Address - Street 1:2501 N GREEN VALLEY PKWY STE 116-118
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89014-0273
Practice Address - Country:US
Practice Address - Phone:702-605-2766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV02294-IOtherBOARD OF EXAMINERSFOR ALCOHOL AND DRUG AND GAMBELING COUNSELORS