Provider Demographics
NPI:1043436991
Name:SMITH, KELLY LYN (MSW)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSW
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 4029
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03302
Mailing Address - Country:US
Mailing Address - Phone:603-491-9244
Mailing Address - Fax:
Practice Address - Street 1:4 BICENTENNIAL SQUARE
Practice Address - Street 2:SUITE 3B
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301
Practice Address - Country:US
Practice Address - Phone:603-491-9244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH11791041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30422542Medicaid