Healthcare Provider Details

I. General information

NPI: 1629983358
Provider Name (Legal Business Name): DEREK SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 S MELROSE DR STE 100
VISTA CA
92081-6669
US

IV. Provider business mailing address

2879 RANCHO CORTES
CARLSBAD CA
92009-3035
US

V. Phone/Fax

Practice location:
  • Phone: 760-500-3325
  • Fax:
Mailing address:
  • Phone: 760-500-3325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122876
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: