Provider Demographics
NPI:1790204980
Name:SMITH, EBONY MICHELLE
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:MICHELLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 N EL DORADO ST
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95202-1305
Mailing Address - Country:US
Mailing Address - Phone:209-938-0228
Mailing Address - Fax:209-938-0281
Practice Address - Street 1:6851 PLYMOUTH RD APT 24
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-2321
Practice Address - Country:US
Practice Address - Phone:209-210-7079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-19
Last Update Date:2017-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)