MEDICARE: MR. KENNETH C SMITH MA

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	LPC7048	SD

General Provider Information

NPI Number	:	1861664351
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KENNETH C SMITH MA

Provider Business Mailing Address
First Line	:	2000 S SYCAMORE AVE
Second Line	:	SUITE 101
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-4263
Country	:	US
Telephone Number	:	605-271-0261
Fax Number	:	605-271-0263

Provider Business Practice Location Address
First Line	:	2000 S SYCAMORE AVE
Second Line	:	SUITE 101
City	:	SIOUX FALLS
State	:	SD
Zip	:	57110-4263
Country	:	US
Telephone Number	:	605-271-0261
Fax Number	:	605-271-0263

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

Provider Enumeration Date	:	03/25/2008
Last Update Date	:	03/25/2008

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