Provider Demographics
NPI:1689896821
Name:SMITH-BURGESS, DONNA (MFT)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:SMITH-BURGESS
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1862 CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1790
Mailing Address - Country:US
Mailing Address - Phone:909-382-7130
Mailing Address - Fax:909-382-7166
Practice Address - Street 1:1454 E 2ND ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-0118
Practice Address - Country:US
Practice Address - Phone:909-382-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC28738106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMFC28738OtherMARRIAGE FAMILY COUNSELOR