Healthcare Provider Details

I. General information

NPI: 1245718501
Provider Name (Legal Business Name): ANGELICA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7592 METROPOLITAN DR STE 404
SAN DIEGO CA
92108-4428
US

IV. Provider business mailing address

5819 LEADROPE WAY
BONITA CA
91902-3035
US

V. Phone/Fax

Practice location:
  • Phone: 619-376-6653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: