Provider Demographics
NPI:1295990539
Name:SMITH, CARLENE (PHD)
Entity type:Individual
Prefix:DR
First Name:CARLENE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 BOARDWALK
Mailing Address - Street 2:SUITIE 304
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2600
Mailing Address - Country:US
Mailing Address - Phone:760-809-3718
Mailing Address - Fax:760-753-6446
Practice Address - Street 1:950 BOARDWALK
Practice Address - Street 2:SUITIE 304
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-2600
Practice Address - Country:US
Practice Address - Phone:760-809-3718
Practice Address - Fax:760-753-6446
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13047103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical