Healthcare Provider Details

I. General information

NPI: 1780116483
Provider Name (Legal Business Name): KIM SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4512
US

IV. Provider business mailing address

8221 WILLOW OAKS CORPORATE DR
FAIRFAX VA
22031-4512
US

V. Phone/Fax

Practice location:
  • Phone: 703-289-2783
  • Fax:
Mailing address:
  • Phone: 703-289-2783
  • Fax: 703-653-6692

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLC6448
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0701004461
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: