Provider Demographics
NPI:1043600893
Name:SMITH, KENNETH EDWARD (D MIN LPC)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:EDWARD
Last Name:SMITH
Suffix:
Gender:M
Credentials:D MIN LPC
Other - Prefix:DR
Other - First Name:KENNETH
Other - Middle Name:EDWARD
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:D MIN, LPC
Mailing Address - Street 1:1125 48TH AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577
Mailing Address - Country:US
Mailing Address - Phone:893-282-1061
Mailing Address - Fax:843-282-1064
Practice Address - Street 1:1125 48TH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:893-282-1061
Practice Address - Fax:843-282-1064
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLPC24101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional