Healthcare Provider Details

I. General information

NPI: 1619004710
Provider Name (Legal Business Name): LESLIE TUCKER SMITH MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6087 FRONT ST SUITE 2
GEORGETOWN CA
95634-9358
US

IV. Provider business mailing address

PO BOX 360
GEORGETOWN CA
95634-0360
US

V. Phone/Fax

Practice location:
  • Phone: 530-919-1616
  • Fax: 530-333-4114
Mailing address:
  • Phone: 530-333-1331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number50124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: