Provider Demographics
NPI:1912561911
Name:SMITH, KRISTIE ANN
Entity Type:Individual
Prefix:
First Name:KRISTIE
Middle Name:ANN
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:PO BOX 919
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92836-0919
Mailing Address - Country:US
Mailing Address - Phone:714-680-9000
Mailing Address - Fax:714-680-8233
Practice Address - Street 1:801 E CHAPMAN AVE STE 203
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-3846
Practice Address - Country:US
Practice Address - Phone:714-680-9000
Practice Address - Fax:714-680-8233
Is Sole Proprietor?:No
Enumeration Date:2019-04-24
Last Update Date:2019-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA90002101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner