1619852522 NPI number — DR. WILBERT SMITH CLINICAL PSYCH

Table of content: DR. WILBERT SMITH CLINICAL PSYCH (NPI 1619852522)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619852522 NPI number — DR. WILBERT SMITH CLINICAL PSYCH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
WILBERT
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
CLINICAL PSYCH
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619852522
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1776
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90001-0776
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-299-5910
Provider Business Mailing Address Fax Number:
310-504-2249

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
877 N DOUGLAS ST., PACIFIC PSYCHOLOGICAL ASS.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL SEGUNDO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-299-5910
Provider Business Practice Location Address Fax Number:
310-504-2249
Provider Enumeration Date:
08/08/2025

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: 103TC0700X , with the licence number:  PSB94028313 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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