Provider Demographics
NPI:1629137740
Name:SMITH, HEATHER LYNN (MA)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
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 578100
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95357-8100
Mailing Address - Country:US
Mailing Address - Phone:209-883-2947
Mailing Address - Fax:209-883-9392
Practice Address - Street 1:4220 KINDRED CT
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-1870
Practice Address - Country:US
Practice Address - Phone:209-521-7254
Practice Address - Fax:209-575-4444
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30960101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor