MEDICARE: KELLY SMYTH-DENT, LLC

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	NLC.0105303	CO

General Provider Information

NPI Number	:	1891150413
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY SMYTH-DENT, LLC

Provider Business Mailing Address
First Line	:	1177 RACE ST
Second Line	:	SUITE 1005
City	:	DENVER
State	:	CO
Zip	:	80206-2813
Country	:	US
Telephone Number	:	336-337-9864
Fax Number	:

Provider Business Practice Location Address
First Line	:	1177 RACE ST
Second Line	:	SUITE 1005
City	:	DENVER
State	:	CO
Zip	:	80206-2813
Country	:	US
Telephone Number	:	336-337-9864
Fax Number	:

Authorized Official
Title or Position	:	MENTAL HEALTH CLINICIAN
Name	:	KELLY LYNN SMYTH-DENT
Credential	:	MA
Telephone Number	:	336-337-9864

Provider Enumeration Date	:	12/24/2015
Last Update Date	:	12/24/2015

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