Provider Demographics
NPI:1497467369
Name:SMITH, CORY ADDISON
Entity type:Individual
Prefix:
First Name:CORY
Middle Name:ADDISON
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 1:5201 DUSTY ROSE WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8148
Mailing Address - Country:US
Mailing Address - Phone:916-541-0551
Mailing Address - Fax:
Practice Address - Street 1:5201 DUSTY ROSE WAY
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-8148
Practice Address - Country:US
Practice Address - Phone:916-541-0551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT134784106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5431234OtherMEDICAL