Provider Demographics
NPI:1982847059
Name:SMITH, CARLA (PSYD)
Entity Type:Individual
Prefix:DR
First Name:CARLA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-5905
Mailing Address - Country:US
Mailing Address - Phone:707-534-6065
Mailing Address - Fax:707-558-8196
Practice Address - Street 1:251 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-5905
Practice Address - Country:US
Practice Address - Phone:707-534-6065
Practice Address - Fax:707-558-8196
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-20
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X, 103TF0200X
CAPSY25810103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program