Basic Information
| Provider Information | |||||||||
| NPI: | 1912446345 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TYFAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCBA, LBA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1169 N. BURLESON BLVD | ||||||||
| Address2: | SUITE 107-344 | ||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822147628 | ||||||||
| FaxNumber: | 8187588015 | ||||||||
| Practice Location | |||||||||
| Address1: | 1169 N. BURLESON BLVD | ||||||||
| Address2: | SUITE 107-344 | ||||||||
| City: | BURLESON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 76028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6822147628 | ||||||||
| FaxNumber: | 8187588015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2017 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/21/2017 | ||||||||
| NPIReactivationDate: | 02/06/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-16-24365 | TX | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-16-24365 | 01 | TX | BACB | OTHER |