Provider Demographics
NPI:1972109536
Name:SMITH, MARY ELLEN ELLEN (MAT FAC)
Entity Type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:ELLEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MAT FAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 DECLARATION DR STE 4
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-4916
Mailing Address - Country:US
Mailing Address - Phone:530-965-5918
Mailing Address - Fax:530-965-5919
Practice Address - Street 1:95 DECLARATION DR STE 4
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-4916
Practice Address - Country:US
Practice Address - Phone:530-965-5918
Practice Address - Fax:530-965-5919
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health