Healthcare Provider Details

I. General information

NPI: 1568653913
Provider Name (Legal Business Name): KIMBERLY K. SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 08/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E BROADWAY STEPHENS COLLEGE, STAMPER COMMONS
COLUMBIA MO
65215-0001
US

IV. Provider business mailing address

1200 E BROADWAY STEPHENS COLLEGE, STAMPER COMMONS
COLUMBIA MO
65215-0001
US

V. Phone/Fax

Practice location:
  • Phone: 573-876-7157
  • Fax:
Mailing address:
  • Phone: 573-876-7157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberSW003197
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberSW003197
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberSW003197
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberSW003197
License Number StateMO
# 5
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License NumberSW003197
License Number StateMO
# 6
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW003197
License Number StateMO
# 7
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberSW003197
License Number StateMO
# 8
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberSW003197
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: