Provider Demographics
NPI:1043628993
Name:SMITH, BRUCE GRAHAM
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:GRAHAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N PACIFIC COAST HWY STE 200A
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-7702
Mailing Address - Country:US
Mailing Address - Phone:310-316-1610
Mailing Address - Fax:310-316-4209
Practice Address - Street 1:901 N PACIFIC COAST HWY STE 200A
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-7702
Practice Address - Country:US
Practice Address - Phone:310-316-1610
Practice Address - Fax:310-316-4209
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2014-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF67490106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist