Healthcare Provider Details

I. General information

NPI: 1083131148
Provider Name (Legal Business Name): VINITA DENISE SMITH-SEPOLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1628 BROADWAY 373 LINFIELD DR.
VALLEJO CA
94590
US

IV. Provider business mailing address

373 LINFIELD DR. 373 LINFIELD DR.
VALLEJO CA
94589
US

V. Phone/Fax

Practice location:
  • Phone: 707-649-8300
  • Fax: 707-649-8302
Mailing address:
  • Phone: 707-644-6766
  • Fax: 707-644-6766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: