MEDICARE: MRS. KIMBERLY DIANE SMITH LCSW INTERN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	IC-571	NV

General Provider Information

NPI Number	:	1407094691
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KIMBERLY DIANE SMITH LCSW INTERN

Provider Business Mailing Address
First Line	:	8685 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-2839
Country	:	US
Telephone Number	:	702-754-0807
Fax Number	:	702-754-0808

Provider Business Practice Location Address
First Line	:	8685 S EASTERN AVE
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89123-2839
Country	:	US
Telephone Number	:	702-754-0807
Fax Number	:	702-754-0808

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/27/2009
Last Update Date	:	03/15/2019

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