Basic Information
| Provider Information | |||||||||
| NPI: | 1326407958 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH SR. | ||||||||
| FirstName: | BYRON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1770 E 118TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900592518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237932375 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1770 E 118TH ST | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900592518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237932375 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2016 | ||||||||
| LastUpdateDate: | 04/16/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PCCI2672 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 1326407958 | 05 | CA | MEDICAID | 7721 | 05 | CA | MEDICAID |