Provider Demographics
NPI:1285805846
Name:SMITH, SAMUEL BARDWELL
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:BARDWELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 LINDA MAR SHOPPING CTR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-3347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1279 LINDA MAR SHOPPING CTR
Practice Address - Street 2:SUITE 112
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-3347
Practice Address - Country:US
Practice Address - Phone:650-228-4981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-21
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 20860103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical