Provider Demographics
NPI:1043419617
Name:SMITH, KIMBERLY M (LICSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 TOLL GATE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-2759
Mailing Address - Country:US
Mailing Address - Phone:401-273-0641
Mailing Address - Fax:401-273-2919
Practice Address - Street 1:215 TOLL GATE RD STE 104
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-4463
Practice Address - Country:US
Practice Address - Phone:401-921-7290
Practice Address - Fax:401-921-6194
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1106791041C0700X
RIISW018881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIKS78986Medicaid