Provider Demographics
NPI:1508972951
Name:SMITH, MICHELLE (REVEREND)
Entity Type:Individual
Prefix:PROF
First Name:MICHELLE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:REVEREND
Other - Prefix:MRS
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MFT-INTERN
Mailing Address - Street 1:6733 DEMARET DR
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95822-3934
Mailing Address - Country:US
Mailing Address - Phone:916-393-7659
Mailing Address - Fax:
Practice Address - Street 1:3990 BRANCH CENTER RD # 95827
Practice Address - Street 2:SERNA CENTER 5735 47TH AVENUE
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-3809
Practice Address - Country:US
Practice Address - Phone:916-743-3856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF40419101YM0800X, 101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA40419OtherBOARD REGISTRATION NUMBER