Healthcare Provider Details

I. General information

NPI: 1033474994
Provider Name (Legal Business Name): SIMONE ANITA SMITH PSYCHOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 04/29/2022
Certification Date: 04/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 MOTOR AVE
LOS ANGELES CA
90034-3710
US

IV. Provider business mailing address

5320 9TH AVE
LOS ANGELES CA
90043-4859
US

V. Phone/Fax

Practice location:
  • Phone: 310-836-1223
  • Fax:
Mailing address:
  • Phone: 323-445-3074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number2013042
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code103TE1100X
TaxonomyExercise & Sports Psychologist
License Number2013042
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License Number2013042
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: