Basic Information
| Provider Information | |||||||||
| NPI: | 1063856201 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 780 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924151003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877194 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 780 E GILBERT ST | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924151003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093877194 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2013 | ||||||||
| LastUpdateDate: | 12/14/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF81751 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 390200000X | CA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 106H00000X | LMFT101028 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.