Provider Demographics
NPI:1356694517
Name:SMITH, LUTHER (MA)
Entity type:Individual
Prefix:MR
First Name:LUTHER
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4215 SPRING ST
Mailing Address - Street 2:#215
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7965
Mailing Address - Country:US
Mailing Address - Phone:619-462-2277
Mailing Address - Fax:
Practice Address - Street 1:4215 SPRING ST
Practice Address - Street 2:215
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7965
Practice Address - Country:US
Practice Address - Phone:619-462-2277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF71042101YP2500X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist