Provider Demographics
NPI:1043720147
Name:SMITH, ROGER JR (RBT)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:SMITH
Suffix:JR
Gender:M
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4241 SOTO ST
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-3446
Mailing Address - Country:US
Mailing Address - Phone:951-283-3663
Mailing Address - Fax:626-602-3875
Practice Address - Street 1:4241 SOTO ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-3446
Practice Address - Country:US
Practice Address - Phone:951-283-3663
Practice Address - Fax:626-602-3875
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-04
Last Update Date:2017-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-17-40349106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician