Provider Demographics
NPI:1073285870
Name:SMITH, KATIE JEANNE (MA, LADC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JEANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10450 GRAND OAKS TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-4241
Mailing Address - Country:US
Mailing Address - Phone:507-381-8165
Mailing Address - Fax:612-879-3796
Practice Address - Street 1:2217 NICOLLET AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3382
Practice Address - Country:US
Practice Address - Phone:612-767-0319
Practice Address - Fax:612-870-3796
Is Sole Proprietor?:No
Enumeration Date:2021-09-30
Last Update Date:2021-09-30
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)