Healthcare Provider Details

I. General information

NPI: 1801416409
Provider Name (Legal Business Name): MELISSA SUZANNE SMITH M.A. EDS, PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 LOW GAP RD
UKIAH CA
95482-3737
US

IV. Provider business mailing address

4860 SILK TREE LN
COOL CA
95614-9481
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-5750
  • Fax:
Mailing address:
  • Phone: 530-401-2917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: