MEDICARE: KENYAH MONET MICKENS-SMITH LMFT, LCAS

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	101YA0400X	Addiction (Substance Use Disorder) Counselor
2	106H00000X	Marriage & Family Therapist	2490

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2490	OTHER	NC	LMFT

General Provider Information

NPI Number	:	1831706704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENYAH MONET MICKENS-SMITH LMFT, LCAS

Provider Business Mailing Address
First Line	:	7745 BALLANTYNE COMMONS PKWY STE 102
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28277-5056
Country	:	US
Telephone Number	:	704-995-0342
Fax Number	:	704-943-0707

Provider Business Practice Location Address
First Line	:	1300 BAXTER ST STE 421
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28204-3026
Country	:	US
Telephone Number	:	704-995-0342
Fax Number	:	704-943-0707

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

Provider Enumeration Date	:	09/25/2020
Last Update Date	:	07/06/2023

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