Provider Demographics
NPI:1538130356
Name:CROSSLEYSMITH, VIRGINIA MARIE (PSYD)
Entity type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:MARIE
Last Name:CROSSLEYSMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1308 WOODSIDE CT
Mailing Address - Street 2:
Mailing Address - City:HEALDSBURG
Mailing Address - State:CA
Mailing Address - Zip Code:95448-3358
Mailing Address - Country:US
Mailing Address - Phone:707-431-7579
Mailing Address - Fax:707-843-5095
Practice Address - Street 1:1212 COLLEGE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-3908
Practice Address - Country:US
Practice Address - Phone:707-431-7579
Practice Address - Fax:707-843-5095
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2017-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA23799103TC0700X
CA208911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA23799OtherLICENSE NUMBER