Healthcare Provider Details

I. General information

NPI: 1154601862
Provider Name (Legal Business Name): MARDI MICHELE SMITH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 04/04/2024
Certification Date: 04/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4546 KENSINGTON DR
SAN DIEGO CA
92116-3834
US

IV. Provider business mailing address

543 JAVELIN CV
CORDOVA TN
38018-7674
US

V. Phone/Fax

Practice location:
  • Phone: 619-994-8627
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number28408
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number2990
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: