Healthcare Provider Details

I. General information

NPI: 1447704770
Provider Name (Legal Business Name): KENNETH DAVID SMITH LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: DAVID SMITH LCSW

II. Dates (important events)

Enumeration Date: 08/03/2016
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 NW WOODSON DR
GRANTS PASS OR
97526-1174
US

IV. Provider business mailing address

524 NW WOODSON DR
GRANTS PASS OR
97526-1174
US

V. Phone/Fax

Practice location:
  • Phone: 541-264-5687
  • Fax: 541-205-9431
Mailing address:
  • Phone: 541-291-1377
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number43576
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number124154
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL11298
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: