Provider Demographics
NPI:1366143562
Name:SMITH, ANTONIO FRANKLIN
Entity type:Individual
Prefix:MR
First Name:ANTONIO
Middle Name:FRANKLIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1406 BANCROFT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5139
Mailing Address - Country:US
Mailing Address - Phone:408-609-0353
Mailing Address - Fax:
Practice Address - Street 1:1406 BANCROFT AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5139
Practice Address - Country:US
Practice Address - Phone:408-609-0353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-14
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT125117106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist