Provider Demographics
NPI:1225205453
Name:SMITH, LEONA M (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LEONA
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 ST JAMES DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403
Mailing Address - Country:US
Mailing Address - Phone:707-571-1714
Mailing Address - Fax:707-541-0675
Practice Address - Street 1:73 ST JAMES DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-571-1714
Practice Address - Fax:707-541-0675
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT24755106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist