Provider Demographics
NPI:1487973020
Name:EALYCORASMITH, ELAINA
Entity type:Individual
Prefix:
First Name:ELAINA
Middle Name:
Last Name:EALYCORASMITH
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 1:2534 SAN FERNANDO WAY
Mailing Address - Street 2:APRT. 2
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-2759
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1735 ENTERPRISE DR
Practice Address - Street 2:SUITE 105A BLDG.1
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-6822
Practice Address - Country:US
Practice Address - Phone:707-425-1799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-21
Last Update Date:2010-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor