Healthcare Provider Details

I. General information

NPI: 1902008097
Provider Name (Legal Business Name): KIMBERLY A SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

558 N TOWNE AVE
POMONA CA
91767-4826
US

IV. Provider business mailing address

PO BOX 335
ANGELUS OAKS CA
92305-0335
US

V. Phone/Fax

Practice location:
  • Phone: 909-622-2273
  • Fax: 909-622-6334
Mailing address:
  • Phone: 909-389-2452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberS0501071320
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: