Provider Demographics
NPI:1912569898
Name:SMITH, ELIZABETH HADDON
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:HADDON
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 1:6049 CLAREMONT AVE APT C
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-1260
Mailing Address - Country:US
Mailing Address - Phone:509-388-8341
Mailing Address - Fax:
Practice Address - Street 1:8945 GOLF LINKS RD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-4124
Practice Address - Country:US
Practice Address - Phone:510-317-1444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103852104100000X
390200000X
CA12857390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker