Healthcare Provider Details

I. General information

NPI: 1689962706
Provider Name (Legal Business Name): NICOLE SMITH PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 DAVIS ST
SAN LEANDRO CA
94577-6923
US

IV. Provider business mailing address

777 DAVIS ST
SAN LEANDRO CA
94577-6923
US

V. Phone/Fax

Practice location:
  • Phone: 510-626-2800
  • Fax:
Mailing address:
  • Phone: 510-626-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number31458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: