Provider Demographics
NPI:1871258558
Name:SMITH, MICHAEL WARREN
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
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 1:25071 YOLANDA AVE
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92551-4536
Mailing Address - Country:US
Mailing Address - Phone:714-430-0758
Mailing Address - Fax:
Practice Address - Street 1:25071 YOLANDA AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92551-4536
Practice Address - Country:US
Practice Address - Phone:714-430-0758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-08
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty