Provider Demographics
NPI:1083276984
Name:SMITH, KYRA IMANI
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:IMANI
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3406
Mailing Address - Country:US
Mailing Address - Phone:626-652-0755
Mailing Address - Fax:
Practice Address - Street 1:2550 E FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91107-3406
Practice Address - Country:US
Practice Address - Phone:626-652-0755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225400000X
CA102916101YM0800X, 104100000X
247200000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program