Provider Demographics
NPI:1114288461
Name:SMOTHERS, KENNETH JAY (M ED, LPC)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:JAY
Last Name:SMOTHERS
Suffix:
Gender:M
Credentials:M ED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 CREEK BEND LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:TX
Mailing Address - Zip Code:78934-2052
Mailing Address - Country:US
Mailing Address - Phone:979-885-2900
Mailing Address - Fax:
Practice Address - Street 1:330 MAIN ST
Practice Address - Street 2:SUITE 7
Practice Address - City:SEALY
Practice Address - State:TX
Practice Address - Zip Code:77474-2391
Practice Address - Country:US
Practice Address - Phone:979-885-2900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-04
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10616101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional