Healthcare Provider Details

I. General information

NPI: 1487095121
Provider Name (Legal Business Name): MS. CAROLE LYNN SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2013
Last Update Date: 07/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

891 MOUNTAIN RANCH RD SUBSTANCE ABUSE PROGRAMS
SAN ANDREAS CA
95249-9713
US

IV. Provider business mailing address

891 MOUNTAIN RANCH RD SUBSTANCE ABUSE PROGRAMS
SAN ANDREAS CA
95249-9713
US

V. Phone/Fax

Practice location:
  • Phone: 209-754-6555
  • Fax: 209-754-6559
Mailing address:
  • Phone: 209-754-6555
  • Fax: 209-754-6559

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: