Provider Demographics
NPI:1003519372
Name:SMITH, KEENAN (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1097
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:MI
Mailing Address - Zip Code:48012-1097
Mailing Address - Country:US
Mailing Address - Phone:248-838-9586
Mailing Address - Fax:
Practice Address - Street 1:2105 112TH AVE NE STE 201
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-2945
Practice Address - Country:US
Practice Address - Phone:425-968-5948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-24
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-82167-102363LP0808X
MI4704370314363LP0808X
WAAP61423786363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health