Provider Demographics
NPI:1174558290
Name:SMITH, EDWARD THOMAS (MA, MFT)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:THOMAS
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1137 N ROSE ST
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-2410
Mailing Address - Country:US
Mailing Address - Phone:818-848-2989
Mailing Address - Fax:818-848-2989
Practice Address - Street 1:210 N PASS AVE STE 203
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3936
Practice Address - Country:US
Practice Address - Phone:818-288-3644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31609101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health