Healthcare Provider Details

I. General information

NPI: 1336496801
Provider Name (Legal Business Name): NICOLE LEEANN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2012
Last Update Date: 08/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

838 BEACH CT.
COLOMA CA
95613-0437
US

IV. Provider business mailing address

PO BOX 143
DIAMOND SPRINGS CA
95619-0143
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-7252
  • Fax:
Mailing address:
  • Phone: 530-903-0648
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCAS R 10652
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: