Provider Demographics
NPI:1508193178
Name:DARTEZ-SMITH, KASHANTA SHANEA
Entity Type:Individual
Prefix:
First Name:KASHANTA
Middle Name:SHANEA
Last Name:DARTEZ-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 1:1653 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-2305
Mailing Address - Country:US
Mailing Address - Phone:209-401-4981
Mailing Address - Fax:
Practice Address - Street 1:1414 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-1515
Practice Address - Country:US
Practice Address - Phone:209-468-2385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-03
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health