Healthcare Provider Details

I. General information

NPI: 1689918229
Provider Name (Legal Business Name): NICOLETTE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2012
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 LONG BEACH BLVD STE A2
LONG BEACH CA
90807-6015
US

IV. Provider business mailing address

1121 ALTO LN
LA HABRA CA
90631-3150
US

V. Phone/Fax

Practice location:
  • Phone: 310-930-7491
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number2187
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: