Basic Information
Provider Information | |||||||||
NPI: | 1467022335 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | MILES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | II | ||||||||
Credential: | PMHNP-BC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SMITH | ||||||||
OtherFirstName: | ROBERT | ||||||||
OtherMiddleName: | MILES | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 1065 NE 125TH STREET | ||||||||
Address2: | SUITE 300 | ||||||||
City: | NORTH MIAMI | ||||||||
State: | FL | ||||||||
PostalCode: | 331615833 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8888526672 | ||||||||
FaxNumber: | 3058914228 | ||||||||
Practice Location | |||||||||
Address1: | 6915 TUTT BLVD. | ||||||||
Address2: | SUITE #110B | ||||||||
City: | COLORADO SPRINGS | ||||||||
State: | CO | ||||||||
PostalCode: | 809233591 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7194451292 | ||||||||
FaxNumber: | 7195916486 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/01/2021 | ||||||||
LastUpdateDate: | 04/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/13/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 1652682 | CO | N |   | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | APN.0997084-NP | CO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.