Provider Demographics
NPI:1336556778
Name:SMITH, WILBUR I
Entity Type:Individual
Prefix:DR
First Name:WILBUR
Middle Name:I
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23120 ALICIA PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692-1210
Mailing Address - Country:US
Mailing Address - Phone:949-770-7375
Mailing Address - Fax:
Practice Address - Street 1:23120 ALICIA PKWY STE 102
Practice Address - Street 2:
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692-1210
Practice Address - Country:US
Practice Address - Phone:949-770-7375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-17
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 3035106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist