Healthcare Provider Details

I. General information

NPI: 1144747783
Provider Name (Legal Business Name): AMY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2017
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1949 AVENIDA DEL ORO STE 118
OCEANSIDE CA
92056-5829
US

IV. Provider business mailing address

29712 ORANGE OAK
LAGUNA NIGUEL CA
92677-1963
US

V. Phone/Fax

Practice location:
  • Phone: 760-945-6500
  • Fax:
Mailing address:
  • Phone: 949-616-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number20826
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: