Provider Demographics
NPI:1215378229
Name:SMITH, DIADRA IMANI (ASW)
Entity Type:Individual
Prefix:
First Name:DIADRA
Middle Name:IMANI
Last Name:SMITH
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 VENICE BLVD APT 301
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-5933
Mailing Address - Country:US
Mailing Address - Phone:973-420-4669
Mailing Address - Fax:
Practice Address - Street 1:2512 ARTESIA BLVD
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90278-3264
Practice Address - Country:US
Practice Address - Phone:562-277-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
CA390200000X
CA1024011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program