Basic Information
| Provider Information | |||||||||
| NPI: | 1417215591 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | DEWAYNE | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941094523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154747310 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1500 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941094523 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154747310 | ||||||||
| FaxNumber: | 4154747300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2012 | ||||||||
| LastUpdateDate: | 02/17/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 172V00000X | CA | Y | Other Service Providers | Community Health Worker |
No ID Information.