Provider Demographics
NPI:1992400949
Name:SMITH, CHARLIE W (AMFT)
Entity type:Individual
Prefix:
First Name:CHARLIE
Middle Name:W
Last Name:SMITH
Suffix:
Gender:M
Credentials:AMFT
Other - Prefix:
Other - First Name:CHARLES
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AMFT
Mailing Address - Street 1:1829 MARKET ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94103-7414
Mailing Address - Country:US
Mailing Address - Phone:415-569-6304
Mailing Address - Fax:415-449-8613
Practice Address - Street 1:1829 MARKET ST STE 202
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94103-7414
Practice Address - Country:US
Practice Address - Phone:415-569-6304
Practice Address - Fax:415-449-8613
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT138551101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health