Healthcare Provider Details

I. General information

NPI: 1639015514
Provider Name (Legal Business Name): EMILY SMITH PH.D., NCSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2026
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4811 RIVERBROOK DR
STOCKTON CA
95219-2016
US

IV. Provider business mailing address

4811 RIVERBROOK DR
STOCKTON CA
95219-2016
US

V. Phone/Fax

Practice location:
  • Phone: 209-953-8450
  • Fax:
Mailing address:
  • Phone: 209-953-8450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number250061310
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: