Healthcare Provider Details

I. General information

NPI: 1861906968
Provider Name (Legal Business Name): TEDDY DIANE SMITH RADT1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 11/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

IV. Provider business mailing address

34966 AVENUE D
YUCAIPA CA
92399-4420
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-6596
  • Fax:
Mailing address:
  • Phone: 909-744-2284
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: