Provider Demographics
NPI:1215646369
Name:SMITH, SARA VANESSA (RADT)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:VANESSA
Last Name:SMITH
Suffix:
Gender:F
Credentials:RADT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47383 DIANE ST
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-8702
Mailing Address - Country:US
Mailing Address - Phone:760-984-7185
Mailing Address - Fax:
Practice Address - Street 1:47383 DIANE ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-8702
Practice Address - Country:US
Practice Address - Phone:760-984-7185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-17
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1443900921101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)