Provider Demographics
NPI:1073726881
Name:SMITH, IRENE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 CAMINO DIABLO
Mailing Address - Street 2:SUITE 200
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596
Mailing Address - Country:US
Mailing Address - Phone:510-527-9747
Mailing Address - Fax:
Practice Address - Street 1:2910 CAMINO DIABLO
Practice Address - Street 2:SUITE 200
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596
Practice Address - Country:US
Practice Address - Phone:510-527-9747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC24657106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist