Provider Demographics
NPI:1053451112
Name:SMYTH, PETER KEVIN (MFT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:KEVIN
Last Name:SMYTH
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1640
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:96093-1640
Mailing Address - Country:US
Mailing Address - Phone:530-623-8285
Mailing Address - Fax:530-623-1447
Practice Address - Street 1:1450 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:CA
Practice Address - Zip Code:96093-1640
Practice Address - Country:US
Practice Address - Phone:530-623-8285
Practice Address - Fax:530-623-1447
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37855106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist