Basic Information
| Provider Information | |||||||||
| NPI: | 1467896035 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | CHEYENNE | ||||||||
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| Credential: | LMFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18612 SANTA ANA AVE. | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094217120 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18612 SANTA ANA AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923162636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094217120 | ||||||||
| FaxNumber: | 9094217128 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 03/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 53298 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.