Provider Demographics
NPI:1972902948
Name:SMITH, BREANNA (MA, AMFT)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:927 N CEDAR ST
Mailing Address - Street 2:#6
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-2083
Mailing Address - Country:US
Mailing Address - Phone:424-204-3526
Mailing Address - Fax:
Practice Address - Street 1:1301 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3124
Practice Address - Country:US
Practice Address - Phone:562-595-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA390200000X
CA117681106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program