Provider Demographics
NPI:1073733739
Name:MITCHELL-SMITH, LOIS JEAN
Entity Type:Individual
Prefix:
First Name:LOIS
Middle Name:JEAN
Last Name:MITCHELL-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 1:5190 ATLANTIC BLVD.
Mailing Address - Street 2:TARZANA TREATMENT CENTERS, INC.
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-4228
Mailing Address - Country:US
Mailing Address - Phone:562-482-4111
Mailing Address - Fax:562-984-5461
Practice Address - Street 1:5190 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90805-6510
Practice Address - Country:US
Practice Address - Phone:562-428-4111
Practice Address - Fax:562-984-5461
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CAIMF80666106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7006Medicaid