Healthcare Provider Details

I. General information

NPI: 1154635175
Provider Name (Legal Business Name): ELIZABETH SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 SUTTON WAY
GRASS VALLEY CA
95945-4144
US

IV. Provider business mailing address

120 N AUBURN ST STE 215
GRASS VALLEY CA
95945-6277
US

V. Phone/Fax

Practice location:
  • Phone: 530-470-2403
  • Fax: 530-271-5943
Mailing address:
  • Phone: 530-559-3357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF72567
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number103941
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: