Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XM0800X | Mental Health | 14417 | CA |
NPI | 1063878460 |
---|---|
Provider Name | Mark Smith |
First Address | San Francisco, CA 94121-1545 |
Second Address | San Francisco, CA 94121-1545 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/01/2016 |
Last Update Date | 14/01/2016 |