Healthcare Provider Details

I. General information

NPI: 1366166738
Provider Name (Legal Business Name): EDWARD ALBERT SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

229 MOCHA COCONUT AVE
NORTH LAS VEGAS NV
89084-1477
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-7475
  • Fax:
Mailing address:
  • Phone: 516-474-5696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number0810008377
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number0810008377
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number0810008377
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: