Healthcare Provider Details

I. General information

NPI: 1275979072
Provider Name (Legal Business Name): ISAAC SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2013
Last Update Date: 06/23/2021
Certification Date: 06/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39420 LIBERTY ST STE 252
FREMONT CA
94538-2297
US

IV. Provider business mailing address

PO BOX 1462
FAIR OAKS CA
95628-1462
US

V. Phone/Fax

Practice location:
  • Phone: 925-825-1793
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number75372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: