MEDICARE: KENOYA SMITH LCSW-A, LP, CDCA

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	130972	OH
2	1041C0700X	Clinical Social Worker	P010794	NC

General Provider Information

NPI Number	:	1942756739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENOYA SMITH LCSW-A, LP, CDCA

Provider Business Mailing Address
First Line	:	3383 HENDERSON DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5231
Country	:	US
Telephone Number	:	912-980-7911
Fax Number	:

Provider Business Practice Location Address
First Line	:	3383 HENDERSON DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-5231
Country	:	US
Telephone Number	:	912-980-7911
Fax Number	:

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

Provider Enumeration Date	:	08/31/2016
Last Update Date	:	08/31/2016

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