=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336615640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BEULAH SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/15/2018
-----------------------------------------------------
Last Update Date | 05/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4321 CALEVARES DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40514-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-886-8572
-----------------------------------------------------
Fax | 606-886-4433
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4321 CALEVARES DR
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40514-1303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-886-8572
-----------------------------------------------------
Fax | 606-886-4433
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 255640
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------