Provider Demographics
NPI:1235338542
Name:SMITH, MARIETTA (MFTI)
Entity Type:Individual
Prefix:
First Name:MARIETTA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 FRANK H OGAWA PLZ STE 175
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-2038
Mailing Address - Country:US
Mailing Address - Phone:510-451-0661
Mailing Address - Fax:510-451-0662
Practice Address - Street 1:300 FRANK H OGAWA PLZ STE 175
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-2038
Practice Address - Country:US
Practice Address - Phone:510-451-0661
Practice Address - Fax:510-451-0662
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF50622390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program