Provider Demographics
NPI:1225144967
Name:SMITH, ANDREW ROY
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:ROY
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 1:7510 SHORELINE DR
Mailing Address - Street 2:STE A-5
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219
Mailing Address - Country:US
Mailing Address - Phone:209-477-1717
Mailing Address - Fax:509-477-1717
Practice Address - Street 1:7510 SHORELINE DR
Practice Address - Street 2:STE A-5
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219
Practice Address - Country:US
Practice Address - Phone:209-477-1717
Practice Address - Fax:509-477-1717
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2020-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15081103T00000X
CAPSY15081103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist