Basic Information
| Provider Information | |||||||||
| NPI: | 1659750784 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MARISA | ||||||||
| MiddleName: | IYAMIDE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 637 SHEPHERD AVE APT A | ||||||||
| Address2: | |||||||||
| City: | HAYWARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945444566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5106485590 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 631 RIVER OAKS PKWY | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951341907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4089147478 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2015 | ||||||||
| LastUpdateDate: | 10/08/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 12153825 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.