Provider Demographics
NPI:1386147445
Name:SMITH, ASIA MONIQUE
Entity type:Individual
Prefix:
First Name:ASIA
Middle Name:MONIQUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15145 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE
Mailing Address - State:CA
Mailing Address - Zip Code:95422-8106
Mailing Address - Country:US
Mailing Address - Phone:707-994-7090
Mailing Address - Fax:707-263-5220
Practice Address - Street 1:6302 13TH AVE
Practice Address - Street 2:
Practice Address - City:LUCERNE
Practice Address - State:CA
Practice Address - Zip Code:95458
Practice Address - Country:US
Practice Address - Phone:707-274-9101
Practice Address - Fax:707-263-5220
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty