Provider Demographics
NPI:1720375561
Name:SUTTON-SMOLIN, MAX BENJAMIN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MAX
Middle Name:BENJAMIN
Last Name:SUTTON-SMOLIN
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:MAX
Other - Middle Name:
Other - Last Name:BENJAMIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:1480 64TH ST STE 150
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-2267
Mailing Address - Country:US
Mailing Address - Phone:415-296-5290
Mailing Address - Fax:
Practice Address - Street 1:1480 64TH ST STE 150
Practice Address - Street 2:
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-2267
Practice Address - Country:US
Practice Address - Phone:415-296-5290
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-30
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CAPSY34100103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program