Provider Demographics
NPI:1376528703
Name:SMITH, DOUGLAS KENT (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:KENT
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:629 CAMINO DE LOS MARES
Mailing Address - Street 2:STE 202A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2834
Mailing Address - Country:US
Mailing Address - Phone:949-481-7755
Mailing Address - Fax:805-688-7712
Practice Address - Street 1:629 CAMINO DE LOS MARES
Practice Address - Street 2:STE 202A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2834
Practice Address - Country:US
Practice Address - Phone:949-481-7755
Practice Address - Fax:949-481-7744
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY8353103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP8353Medicare PIN
CACP8353Medicare ID - Type UnspecifiedCLINICAL PSYCHOLOGIST