Provider Demographics
NPI:1689825705
Name:SMITH, GINA R (MA)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:R
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 1:4025 CAMINO DEL RIO S STE 250
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-4100
Mailing Address - Country:US
Mailing Address - Phone:619-858-3105
Mailing Address - Fax:619-280-5420
Practice Address - Street 1:4025 CAMINO DEL RIO S STE 250
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4100
Practice Address - Country:US
Practice Address - Phone:619-858-3105
Practice Address - Fax:619-280-5420
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2017-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT52269106H00000X
101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist