Provider Demographics
NPI:1093900151
Name:SMITH, ANGLA A
Entity Type:Individual
Prefix:MS
First Name:ANGLA
Middle Name:A
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 1:780 E GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92415-0026
Mailing Address - Country:US
Mailing Address - Phone:909-387-7756
Mailing Address - Fax:909-387-7386
Practice Address - Street 1:15345 BONANZA RD
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2499
Practice Address - Country:US
Practice Address - Phone:760-552-6644
Practice Address - Fax:909-387-7386
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-12
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 101YM0800X, 106H00000X, 390200000X
CA101YM0800X
CA136276106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program