Healthcare Provider Details

I. General information

NPI: 1932811809
Provider Name (Legal Business Name): SHAQUILA SHANTEL MARIE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2022
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 TELEGRAPH AVE
BERKELEY CA
94705-1118
US

IV. Provider business mailing address

542 S 19TH ST
RICHMOND CA
94804-3804
US

V. Phone/Fax

Practice location:
  • Phone: 510-123-4567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number141985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: