Provider Demographics
NPI:1225049901
Name:SMITH, KELLY RAYE (LCSW, ACSW)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:RAYE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:RAYE
Other - Last Name:MCKAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:600 CENTRAL AVE STE 208
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-3141
Mailing Address - Country:US
Mailing Address - Phone:406-231-1775
Mailing Address - Fax:406-403-0660
Practice Address - Street 1:600 CENTRAL AVE STE 208
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401
Practice Address - Country:US
Practice Address - Phone:406-231-1775
Practice Address - Fax:406-403-0660
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2018-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT743-LCSW1041C0700X
MT7431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0000071565OtherBLUE CROSS/SHIELD OF MONT
WYLCSW-503OtherWYOMING LCSW LICENSE
MT000050294Medicare ID - Type UnspecifiedMEDICARE PART B PROVIDER