Provider Demographics
NPI:1073375721
Name:SMITH, KAILANI
Entity Type:Individual
Prefix:
First Name:KAILANI
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5669 AMAYA DR APT 376
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-5609
Mailing Address - Country:US
Mailing Address - Phone:510-856-8742
Mailing Address - Fax:
Practice Address - Street 1:3878 RUFFIN RD STE B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1842
Practice Address - Country:US
Practice Address - Phone:619-739-4569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician