Basic Information
| Provider Information | |||||||||
| NPI: | 1043628993 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | GRAHAM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 901 N PACIFIC COAST HWY STE 200A | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902777702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103161610 | ||||||||
| FaxNumber: | 3103164209 | ||||||||
| Practice Location | |||||||||
| Address1: | 901 N PACIFIC COAST HWY STE 200A | ||||||||
| Address2: | |||||||||
| City: | REDONDO BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902777702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3103161610 | ||||||||
| FaxNumber: | 3103164209 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/23/2014 | ||||||||
| LastUpdateDate: | 07/23/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | IMF67490 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.