Provider Demographics
NPI:1902945496
Name:SMITH, RONALD RUSSELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:RUSSELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1503 NAPOLI WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-5272
Mailing Address - Country:US
Mailing Address - Phone:951-487-0027
Mailing Address - Fax:
Practice Address - Street 1:17216 SLOVER AVE STE L
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92337-7580
Practice Address - Country:US
Practice Address - Phone:909-854-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY13539103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical