Provider Demographics
NPI:1821408949
Name:SMITH, GARRAN ALEXANDER
Entity type:Individual
Prefix:
First Name:GARRAN
Middle Name:ALEXANDER
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 1:8014 MANGO AVE
Mailing Address - Street 2:APT F75
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3352
Mailing Address - Country:US
Mailing Address - Phone:909-900-7710
Mailing Address - Fax:
Practice Address - Street 1:8014 MANGO AVE
Practice Address - Street 2:APT F75
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3352
Practice Address - Country:US
Practice Address - Phone:909-900-7710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000000000000Medicaid