Provider Demographics
NPI:1578034237
Name:SUNDGOT-SMITH, JUSTIN BENGT
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:BENGT
Last Name:SUNDGOT-SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5266 HOLLISTER AVE STE 212
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93111-4041
Mailing Address - Country:US
Mailing Address - Phone:805-613-7024
Mailing Address - Fax:
Practice Address - Street 1:5266 HOLLISTER AVE STE 212
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93111-4041
Practice Address - Country:US
Practice Address - Phone:805-452-7356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112952101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA832668750OtherIRS