Provider Demographics
NPI:1679013858
Name:SMITH, OPHELIA DENISE
Entity type:Individual
Prefix:MISS
First Name:OPHELIA
Middle Name:DENISE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 278866
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-8866
Mailing Address - Country:US
Mailing Address - Phone:916-410-0119
Mailing Address - Fax:916-274-4920
Practice Address - Street 1:103 D ST
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-6017
Practice Address - Country:US
Practice Address - Phone:530-671-3427
Practice Address - Fax:530-671-3877
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA96913106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOtherTAXONOMY