Healthcare Provider Details

I. General information

NPI: 1649578204
Provider Name (Legal Business Name): KIMMIE SMITH MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISSY SMITH LPC

II. Dates (important events)

Enumeration Date: 03/07/2011
Last Update Date: 10/20/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 ZIMOVIA HWY APT 2
WRANGELL AK
99929
US

IV. Provider business mailing address

PO BOX 1231
WRANGELL AK
99929-1231
US

V. Phone/Fax

Practice location:
  • Phone: 907-305-0985
  • Fax:
Mailing address:
  • Phone: 907-874-2373
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number147993
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: