Provider Demographics
NPI:1134646359
Name:SMITH, DELORES (CAADE CATCI #6963)
Entity Type:Individual
Prefix:MS
First Name:DELORES
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CAADE CATCI #6963
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9055 ORION AVE APT 5
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-4240
Mailing Address - Country:US
Mailing Address - Phone:818-277-3773
Mailing Address - Fax:
Practice Address - Street 1:9055 ORION AVE APT 5
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-4240
Practice Address - Country:US
Practice Address - Phone:818-277-3773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6963101YA0400X
CA6963I101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6963IOtherCAADE