Provider Demographics
NPI:1992225759
Name:SMITH, AMBER DANIELLE
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:DANIELLE
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 1:1030 S HUTCHINS ST STE 4-188
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-5254
Mailing Address - Country:US
Mailing Address - Phone:209-329-6217
Mailing Address - Fax:
Practice Address - Street 1:222 W LOCKEFORD ST STE 5
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-2053
Practice Address - Country:US
Practice Address - Phone:209-329-6217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-22
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139545106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist