MEDICARE: MRS. KIM MARIE SMITH LCSW, LMFT

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	101YM0800X	Mental Health Counselor	34002738A	IN
2	1041C0700X	Clinical Social Worker

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	064061000	OTHER		MAGELLAN
2	090831	OTHER		MHN
3	000000200512	OTHER	IN	ANTHEM BLUE CROSS BLUE SH

General Provider Information

NPI Number	:	1558493056
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIM MARIE SMITH LCSW, LMFT

Provider Business Mailing Address
First Line	:	3266 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2883
Country	:	US
Telephone Number	:	260-436-5986
Fax Number	:	260-436-1859

Provider Business Practice Location Address
First Line	:	3266 MALLARD COVE LN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46804-2883
Country	:	US
Telephone Number	:	260-436-5986
Fax Number	:	260-436-1859

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

Provider Enumeration Date	:	03/10/2007
Last Update Date	:	02/26/2025

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