=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780852442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYLE S SMITH LBSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2008
-----------------------------------------------------
Last Update Date | 02/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6051 FRANKFORT HWY STE 200
-----------------------------------------------------
City | BENZONIA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49616-9651
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-398-2013
-----------------------------------------------------
Fax | 231-882-2360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7191 FAWN DR
-----------------------------------------------------
City | CADILLAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49601-9335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6802081145
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------