Provider Demographics
NPI:1265573299
Name:SMITH, JOHN KEITH (PHD, LCSW)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEITH
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2269 BOWDOIN ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-2715
Mailing Address - Country:US
Mailing Address - Phone:714-812-6939
Mailing Address - Fax:413-638-8820
Practice Address - Street 1:500 W BADILLO ST
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-3762
Practice Address - Country:US
Practice Address - Phone:626-859-2686
Practice Address - Fax:626-859-2685
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-11
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS198681041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALCS19868Medicare ID - Type Unspecified