Provider Demographics
NPI:1487184123
Name:SMITH, ROBERTA JEAN (CPED)
Entity Type:Individual
Prefix:MS
First Name:ROBERTA
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 DOLLIVER
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449
Mailing Address - Country:US
Mailing Address - Phone:805-773-5571
Mailing Address - Fax:805-773-1270
Practice Address - Street 1:801 DOLLIVER ST
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-2503
Practice Address - Country:US
Practice Address - Phone:805-773-5571
Practice Address - Fax:805-773-1270
Is Sole Proprietor?:No
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPED3993224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist