Provider Demographics
NPI:1164888244
Name:SMILACK, EVELINE (MFA, MA, LMFT)
Entity Type:Individual
Prefix:
First Name:EVELINE
Middle Name:
Last Name:SMILACK
Suffix:
Gender:F
Credentials:MFA, MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 PIER AVE # 278
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-5311
Mailing Address - Country:US
Mailing Address - Phone:310-869-1533
Mailing Address - Fax:
Practice Address - Street 1:270 26TH ST STE 205
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90402-2543
Practice Address - Country:US
Practice Address - Phone:310-869-1533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-05
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91090106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist