Provider Demographics
NPI:1588285134
Name:SMITH, KIERSTEN M (RADT)
Entity type:Individual
Prefix:MS
First Name:KIERSTEN
Middle Name:M
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 1:808 AMADOR CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92530-1862
Mailing Address - Country:US
Mailing Address - Phone:714-331-5554
Mailing Address - Fax:
Practice Address - Street 1:808 AMADOR CT
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-1862
Practice Address - Country:US
Practice Address - Phone:714-331-5554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-05
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1364550919324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility