Healthcare Provider Details

I. General information

NPI: 1669568366
Provider Name (Legal Business Name): KIM SMITH PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 INDIAN SCHOOL RD NE STE 200
ALBUQUERQUE NM
87110-3970
US

IV. Provider business mailing address

4801 INDIAN SCHOOL RD NE STE 200
ALBUQUERQUE NM
87110-3970
US

V. Phone/Fax

Practice location:
  • Phone: 505-884-8595
  • Fax: 505-281-1049
Mailing address:
  • Phone: 505-884-8595
  • Fax: 505-281-1049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number325
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: