Healthcare Provider Details

I. General information

NPI: 1619852522
Provider Name (Legal Business Name): WILBERT SMITH CLINICAL PSYCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2025
Last Update Date: 08/08/2026
Certification Date: 08/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 N DOUGLAS ST., PACIFIC PSYCHOLOGICAL ASS.
EL SEGUNDO CA
90242
US

IV. Provider business mailing address

PO BOX 1776
LOS ANGELES CA
90001-0776
US

V. Phone/Fax

Practice location:
  • Phone: 310-299-5910
  • Fax: 310-504-2249
Mailing address:
  • Phone: 310-299-5910
  • Fax: 310-504-2249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberPSB94028313
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: