Provider Demographics
NPI:1760131734
Name:SMITH, CHRISTIAN OTTO
Entity Type:Individual
Prefix:
First Name:CHRISTIAN
Middle Name:OTTO
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:528 HIBISCUS DR APT B108
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-6194
Mailing Address - Country:US
Mailing Address - Phone:909-560-7993
Mailing Address - Fax:
Practice Address - Street 1:1301 E ORANGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6807
Practice Address - Country:US
Practice Address - Phone:800-249-1266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-18
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician