MEDICARE: TERESA SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YS0200X	School Counselor

General Provider Information

NPI Number	:	1770613341
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TERESA SMITH

Provider Business Mailing Address
First Line	:	1340 TROMBETTA ST
Second Line	:
City	:	SANTA ROSA
State	:	CA
Zip	:	95407-8911
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1800 GRAVENSTEIN HWY N
Second Line	:
City	:	SEBASTOPOL
State	:	CA
Zip	:	95472-2607
Country	:	US
Telephone Number	:	707-823-7300
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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Directions to “ TERESA SMITH ” Practice Location

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