Provider Demographics
NPI:1629423827
Name:SMITH-CONN, AUDRINA
Entity Type:Individual
Prefix:
First Name:AUDRINA
Middle Name:
Last Name:SMITH-CONN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 PARK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2277
Mailing Address - Country:US
Mailing Address - Phone:108-770-7115
Mailing Address - Fax:
Practice Address - Street 1:1335 PARK AVE STE A
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-2277
Practice Address - Country:US
Practice Address - Phone:510-877-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA110087106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program