Healthcare Provider Details

I. General information

NPI: 1316166077
Provider Name (Legal Business Name): MS. DIANI SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2118 S. CENTRAL AVE.
LOS ANGELES CA
90011
US

IV. Provider business mailing address

855 VICTOR AVE APT. #108
INGLEWOOD CA
90302-2640
US

V. Phone/Fax

Practice location:
  • Phone: 213-493-4664
  • Fax: 213-537-0110
Mailing address:
  • Phone: 310-400-4339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: