Provider Demographics
NPI:1922259530
Name:SMITH, AMY ANNMARIE
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ANNMARIE
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 1:219 N INDIAN HILL BLVD STE 202A
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-4644
Mailing Address - Country:US
Mailing Address - Phone:909-973-8915
Mailing Address - Fax:
Practice Address - Street 1:219 N INDIAN HILL BLVD STE 202A
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-4644
Practice Address - Country:US
Practice Address - Phone:909-973-8915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-02
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95-1946482Medicaid