=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023588506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIMONE SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2018
-----------------------------------------------------
Last Update Date | 11/28/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 424 PENINSULA AVE
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-1653
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-286-4396
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3106 SERRA WAY
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94534-3343
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-712-0192
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------