Provider Demographics
NPI:1437988912
Name:SMITH FOSTIN, CANICIA QUEENCY
Entity type:Individual
Prefix:MRS
First Name:CANICIA
Middle Name:QUEENCY
Last Name:SMITH FOSTIN
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 1:9479 NW 38TH PL
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33351-5909
Mailing Address - Country:US
Mailing Address - Phone:954-529-7429
Mailing Address - Fax:
Practice Address - Street 1:7520 NW 5TH ST STE 203
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-1613
Practice Address - Country:US
Practice Address - Phone:954-529-7429
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-31
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH24093101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health