=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225593023
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY SMARTT MS, LMFT-ASSOCIATE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2019
-----------------------------------------------------
Last Update Date | 02/05/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5220 SPRING VALLEY RD STE 122
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75254-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-546-9625
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5801 BROADMOOR DR
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75093-7830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-552-7499
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 203361
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------