Healthcare Provider Details

I. General information

NPI: 1538913132
Provider Name (Legal Business Name): MISS MARIAH MARIE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

944 N ST
EUREKA CA
95501-2045
US

IV. Provider business mailing address

PO BOX 6310
EUREKA CA
95502-6310
US

V. Phone/Fax

Practice location:
  • Phone: 74-430-5147
  • Fax: 707-442-1191
Mailing address:
  • Phone: 707-443-4237
  • Fax: 707-442-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1073023107
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: