Healthcare Provider Details

I. General information

NPI: 1447740295
Provider Name (Legal Business Name): KEITH A SMITH LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2018
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

IV. Provider business mailing address

90 HOPE DR BLDG 6000
MOUNTAIN HOME AFB ID
83648-1062
US

V. Phone/Fax

Practice location:
  • Phone: 208-828-7736
  • Fax:
Mailing address:
  • Phone: 208-828-7736
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number1271991
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: