Provider Demographics
NPI:1639859820
Name:SMITH, REBECCA DIANA (PSYD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:DIANA
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10231 CORFU DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-9681
Mailing Address - Country:US
Mailing Address - Phone:916-834-1375
Mailing Address - Fax:
Practice Address - Street 1:3825 HOPYARD RD STE 202
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8528
Practice Address - Country:US
Practice Address - Phone:925-847-5051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY34331103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical