Healthcare Provider Details

I. General information

NPI: 1366834129
Provider Name (Legal Business Name): KIMBERLY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 COUNTRY CLUB DR
ASHLAND KY
41101-2136
US

IV. Provider business mailing address

106 COUNTRY CLUB DR
ASHLAND KY
41101-2136
US

V. Phone/Fax

Practice location:
  • Phone: 606-371-0224
  • Fax:
Mailing address:
  • Phone: 606-371-0224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License NumberOH3021991
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number200122906
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: