Provider Demographics
NPI:1033345095
Name:SMITH, KATHERYN ELIZABETH (MA)
Entity Type:Individual
Prefix:MS
First Name:KATHERYN
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 ROCKPORT DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-6925
Mailing Address - Country:US
Mailing Address - Phone:910-960-7768
Mailing Address - Fax:910-438-0906
Practice Address - Street 1:555 EXECUTIVE PL STE 202
Practice Address - Street 2:INTEGRATED BEHAVIORAL HEALTHCARE SERVICES, INC.
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5155
Practice Address - Country:US
Practice Address - Phone:910-438-0947
Practice Address - Fax:910-438-0906
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6941101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6115059Medicaid
418620OtherMHN PIN