Provider Demographics
NPI:1053516740
Name:SMITH, STEPHEN R (MFT-I, RAS)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:MFT-I, RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 LOCH LOMOND DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-5196
Mailing Address - Country:US
Mailing Address - Phone:707-454-0256
Mailing Address - Fax:
Practice Address - Street 1:1286 CALLEN ST
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-3002
Practice Address - Country:US
Practice Address - Phone:707-447-8982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF45432106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist