Provider Demographics
NPI:1124585542
Name:SMITH, RONALD LAURENCE
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:LAURENCE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 N 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-1124
Mailing Address - Country:US
Mailing Address - Phone:619-426-4801
Mailing Address - Fax:619-426-0034
Practice Address - Street 1:73 N 2ND AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-1124
Practice Address - Country:US
Practice Address - Phone:619-426-4801
Practice Address - Fax:619-426-0034
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACADTPR6869101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)