Provider Demographics
NPI:1336496801
Name:SMITH, NICOLE LEEANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEEANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 143
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-0143
Mailing Address - Country:US
Mailing Address - Phone:530-903-0648
Mailing Address - Fax:
Practice Address - Street 1:838 BEACH CT.
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:CA
Practice Address - Zip Code:95613-0437
Practice Address - Country:US
Practice Address - Phone:530-626-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAS R 10652101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)