1508972951 NPI number — PROF. MICHELLE SMITH REVEREND

Table of content: PROF. MICHELLE SMITH REVEREND (NPI 1508972951)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508972951 NPI number — PROF. MICHELLE SMITH REVEREND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MICHELLE
Provider Middle Name:
Provider Name Prefix Text:
PROF.
Provider Name Suffix Text:
Provider Credential Text:
REVEREND
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SMITH
Provider Other First Name:
MICHELLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MFT-INTERN
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1508972951
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6733 DEMARET DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95822-3934
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-393-7659
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3990 BRANCH CENTER RD # 95827
Provider Second Line Business Practice Location Address:
SERNA CENTER 5735 47TH AVENUE
Provider Business Practice Location Address City Name:
SACRAMENTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95827-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-743-3856
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  IMF40419 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 101YP1600X , with the licence number: IMF40419 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 40419 . This is a "BOARD REGISTRATION NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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