Provider Demographics
NPI:1942926340
Name:SMITH, AMBER KRISTINA
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:KRISTINA
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 1:633 SOUTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-1547
Mailing Address - Country:US
Mailing Address - Phone:279-336-1982
Mailing Address - Fax:
Practice Address - Street 1:633 SOUTHWOOD DR
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-1547
Practice Address - Country:US
Practice Address - Phone:279-336-1982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician