Healthcare Provider Details

I. General information

NPI: 1013407006
Provider Name (Legal Business Name): KIMRON SMITH MA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2018
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7550 PINES ROAD SUITE 1115
SHREVEPORT LA
71129
US

IV. Provider business mailing address

6014 ALYCIA NIKOLE LN
SHREVEPORT LA
71129-4357
US

V. Phone/Fax

Practice location:
  • Phone: 318-683-4086
  • Fax:
Mailing address:
  • Phone: 318-820-1985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: