Healthcare Provider Details

I. General information

NPI: 1316270291
Provider Name (Legal Business Name): RYAN CHANDLER SMITH ACSW, CLINICIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2009
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3636 N 1ST ST STE 124&112
FRESNO CA
93726-6800
US

IV. Provider business mailing address

3636 N 1ST ST STE 124&112
FRESNO CA
93726-6800
US

V. Phone/Fax

Practice location:
  • Phone: 559-476-2177
  • Fax:
Mailing address:
  • Phone: 559-476-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW86439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: