Provider Demographics
NPI:1932773579
Name:SMITH, DENISE M (SUDCC)
Entity type:Individual
Prefix:MS
First Name:DENISE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1981 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-2720
Mailing Address - Country:US
Mailing Address - Phone:209-870-6525
Mailing Address - Fax:209-337-2108
Practice Address - Street 1:1981 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-2720
Practice Address - Country:US
Practice Address - Phone:209-870-6525
Practice Address - Fax:209-337-2108
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7568101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)