Provider Demographics
NPI:1932598828
Name:SMITH, ROSE HICKMAN (LMFT)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:HICKMAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:HICKMAN
Other - Last Name:RIGOLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:4519 ADMIRALTY WAY
Mailing Address - Street 2:SUITE 202B
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5441
Mailing Address - Country:US
Mailing Address - Phone:424-571-2273
Mailing Address - Fax:
Practice Address - Street 1:4519 ADMIRALTY WAY
Practice Address - Street 2:SUITE 202B
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-5441
Practice Address - Country:US
Practice Address - Phone:424-571-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA83810106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist