Healthcare Provider Details

I. General information

NPI: 1639656275
Provider Name (Legal Business Name): ANTOINETTE KATHLEEN SMITH AAC, CDPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2018
Last Update Date: 07/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1616 S GOLD ST STE 4
CENTRALIA WA
98531-8930
US

IV. Provider business mailing address

1616 S GOLD ST STE 4
CENTRALIA WA
98531-8930
US

V. Phone/Fax

Practice location:
  • Phone: 360-807-4929
  • Fax: 360-807-4160
Mailing address:
  • Phone: 360-807-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCO60802177
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberCG60783142
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: