Provider Demographics
NPI:1033433818
Name:SMITH, KELVIN
Entity Type:Individual
Prefix:
First Name:KELVIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 TRANQUIL LN
Mailing Address - Street 2:
Mailing Address - City:PHENIX CITY
Mailing Address - State:AL
Mailing Address - Zip Code:36867-8542
Mailing Address - Country:US
Mailing Address - Phone:334-480-0852
Mailing Address - Fax:
Practice Address - Street 1:2100 COMER AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-8725
Practice Address - Country:US
Practice Address - Phone:706-596-5583
Practice Address - Fax:706-596-5589
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker