Provider Demographics
NPI:1982781084
Name:SMITH, RICHARD KEANE (PHD CRC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:KEANE
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6037 EASTWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:ALTA LOMA
Mailing Address - State:CA
Mailing Address - Zip Code:91737
Mailing Address - Country:US
Mailing Address - Phone:760-240-3217
Mailing Address - Fax:760-240-3274
Practice Address - Street 1:9775 MOCKINGBIRD AVE
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92308
Practice Address - Country:US
Practice Address - Phone:760-240-3217
Practice Address - Fax:760-240-3274
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13809103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPL138190Medicare ID - Type Unspecified