Provider Demographics
NPI:1629884705
Name:SMITH, SHANDELL
Entity type:Individual
Prefix:
First Name:SHANDELL
Middle Name:
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 1:6316 N 51ST AVE
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-1331
Mailing Address - Country:US
Mailing Address - Phone:402-880-2762
Mailing Address - Fax:
Practice Address - Street 1:6316 N 51ST AVE
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-1331
Practice Address - Country:US
Practice Address - Phone:402-880-2762
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP-2214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)