Healthcare Provider Details

I. General information

NPI: 1376690073
Provider Name (Legal Business Name): CHARLES EDWARD SMITH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 12/14/2025
Certification Date: 12/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7332 GREAT EGRET BLVD
SARASOTA FL
34241-2717
US

IV. Provider business mailing address

1305 N H ST STE A-115
LOMPOC CA
93436-8138
US

V. Phone/Fax

Practice location:
  • Phone: 805-588-3221
  • Fax: 805-733-1213
Mailing address:
  • Phone: 805-588-3221
  • Fax: 805-733-1213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY11622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: