Provider Demographics
NPI:1578263018
Name:SMITH, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 N EAST ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3327
Mailing Address - Country:US
Mailing Address - Phone:501-381-2001
Mailing Address - Fax:501-381-2005
Practice Address - Street 1:910 N EAST ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3327
Practice Address - Country:US
Practice Address - Phone:501-381-2001
Practice Address - Fax:501-381-2005
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARRBT-22-233347106S00000X
AR171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician