Provider Demographics
NPI:1710108311
Name:SMITH, JOHN M (LCSW)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7734 HERSCHEL AVE., SUITE E
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:AR
Mailing Address - Zip Code:92037
Mailing Address - Country:US
Mailing Address - Phone:858-459-6341
Mailing Address - Fax:
Practice Address - Street 1:7734 HERSCHEL AVE., SUITE E
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:AR
Practice Address - Zip Code:92037
Practice Address - Country:US
Practice Address - Phone:858-459-6341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS141141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical