MEDICARE: KENNETH PERRY SMITH LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	5086	SC

General Provider Information

NPI Number	:	1194050336
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNETH PERRY SMITH LPC

Provider Business Mailing Address
First Line	:	44 MOUNT VISTA AVE
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-1119
Country	:	US
Telephone Number	:	864-546-8027
Fax Number	:	864-355-9752

Provider Business Practice Location Address
First Line	:	44 MOUNT VISTA AVE
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29605-1119
Country	:	US
Telephone Number	:	864-546-8027
Fax Number	:	864-355-9752

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/06/2009
Last Update Date	:	10/06/2009

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