Provider Demographics
NPI:1043795644
Name:ABLES-SMITH, BOBBIE RENEE (LEP #3049)
Entity Type:Individual
Prefix:
First Name:BOBBIE
Middle Name:RENEE
Last Name:ABLES-SMITH
Suffix:
Gender:F
Credentials:LEP #3049
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 E VINE ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-3179
Mailing Address - Country:US
Mailing Address - Phone:209-331-7085
Mailing Address - Fax:
Practice Address - Street 1:1305 E VINE ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3179
Practice Address - Country:US
Practice Address - Phone:209-331-7085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3049103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool