Provider Demographics
NPI:1952127466
Name:SMITH, JOHN (R1585691024)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:R1585691024
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12781 JOSEPHINE ST
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4622
Mailing Address - Country:US
Mailing Address - Phone:657-340-0788
Mailing Address - Fax:
Practice Address - Street 1:12781 JOSEPHINE ST
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4622
Practice Address - Country:US
Practice Address - Phone:657-340-0788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-29
Last Update Date:2024-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1585691024101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)