Healthcare Provider Details

I. General information

NPI: 1710448436
Provider Name (Legal Business Name): TONETTA MARIE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3322 SWEETWATER BLVD, STE 102
SPRING VALLEY CA
91977
US

IV. Provider business mailing address

9445 FARNHAM ST STE 100
SAN DIEGO CA
92123-1399
US

V. Phone/Fax

Practice location:
  • Phone: 858-380-4676
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC6049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: