Provider Demographics
NPI:1750463139
Name:SMITH, CAROLYN JEANNE (MFT)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:JEANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:MS
Other - First Name:CARRIE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MFT
Mailing Address - Street 1:175 S HUMBOLDT ST
Mailing Address - Street 2:
Mailing Address - City:WILLITS
Mailing Address - State:CA
Mailing Address - Zip Code:95490-3511
Mailing Address - Country:US
Mailing Address - Phone:530-570-4474
Mailing Address - Fax:
Practice Address - Street 1:175 S HUMBOLDT ST
Practice Address - Street 2:
Practice Address - City:WILLITS
Practice Address - State:CA
Practice Address - Zip Code:95490-3511
Practice Address - Country:US
Practice Address - Phone:530-570-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA27544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27544OtherMFT