Healthcare Provider Details

I. General information

NPI: 1689766164
Provider Name (Legal Business Name): MARILYN VIRGINIA SMITH LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2006
Last Update Date: 04/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 E 4TH ST SUITE G-152
SANTA ANA CA
92705-3940
US

IV. Provider business mailing address

2030 E 4TH ST SUITE G-152
SANTA ANA CA
92705-3940
US

V. Phone/Fax

Practice location:
  • Phone: 949-466-3213
  • Fax:
Mailing address:
  • Phone: 949-466-3213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW22298
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number22298
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: