Healthcare Provider Details

I. General information

NPI: 1659664910
Provider Name (Legal Business Name): KAITLIN M SMITH PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2011
Last Update Date: 05/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 KLOTZ RD
BOWLING GREEN OH
43402-4820
US

IV. Provider business mailing address

410 N PROSPECT ST
BOWLING GREEN OH
43402-2021
US

V. Phone/Fax

Practice location:
  • Phone: 419-352-7588
  • Fax: 419-354-4977
Mailing address:
  • Phone: 419-308-5383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC0900482
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: