Provider Demographics
NPI:1558779371
Name:SMITH, SHANETTE (IMF)
Entity Type:Individual
Prefix:
First Name:SHANETTE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:IMF
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 1094
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1094
Mailing Address - Country:US
Mailing Address - Phone:619-832-5643
Mailing Address - Fax:
Practice Address - Street 1:1855 1ST AVE STE 201B
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2685
Practice Address - Country:US
Practice Address - Phone:619-832-5643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2020-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist