Healthcare Provider Details

I. General information

NPI: 1174404701
Provider Name (Legal Business Name): HEATHER SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2844 COLOMA ST
PLACERVILLE CA
95667-4406
US

IV. Provider business mailing address

3024 COURTSIDE DR
DIAMOND SPRINGS CA
95619-9283
US

V. Phone/Fax

Practice location:
  • Phone: 530-626-9240
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95231082
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: