Provider Demographics
NPI:1598437956
Name:SMITH, SLOANE K (SUDRC #12356)
Entity Type:Individual
Prefix:
First Name:SLOANE
Middle Name:K
Last Name:SMITH
Suffix:
Gender:F
Credentials:SUDRC #12356
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 S BEACON ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-4324
Mailing Address - Country:US
Mailing Address - Phone:310-514-4940
Mailing Address - Fax:
Practice Address - Street 1:132 W 10TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3702
Practice Address - Country:US
Practice Address - Phone:310-872-5939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-04
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12356101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)