Provider Demographics
NPI:1659403178
Name:SMITH, SIDNEY MARK (PHD)
Entity Type:Individual
Prefix:MRS
First Name:SIDNEY
Middle Name:MARK
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1270 NATIVIDAD RD RM 200
Mailing Address - Street 2:
Mailing Address - City:SALINAS
Mailing Address - State:CA
Mailing Address - Zip Code:93906-3122
Mailing Address - Country:US
Mailing Address - Phone:831-755-4510
Mailing Address - Fax:
Practice Address - Street 1:1270 NATIVIDAD RD RM 200
Practice Address - Street 2:
Practice Address - City:SALINAS
Practice Address - State:CA
Practice Address - Zip Code:93906-3122
Practice Address - Country:US
Practice Address - Phone:831-755-4510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10727103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent