Provider Demographics
NPI:1902409089
Name:SMITH, LIBERTY FAITH
Entity Type:Individual
Prefix:
First Name:LIBERTY
Middle Name:FAITH
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 1:1957 CARLETON ST
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-1422
Mailing Address - Country:US
Mailing Address - Phone:530-782-9123
Mailing Address - Fax:
Practice Address - Street 1:980 PLACER ST
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-1126
Practice Address - Country:US
Practice Address - Phone:530-246-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA92610350D49354OtherMEDI-CAL