Provider Demographics
NPI:1235689902
Name:SMITH, KATHLEEN RENE (SE202993)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:RENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:SE202993
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:RENE
Other - Last Name:SCHROEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-2408
Practice Address - Street 1:1000 N 8TH AVE
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5757
Practice Address - Country:US
Practice Address - Phone:208-232-6260
Practice Address - Fax:208-232-6259
Is Sole Proprietor?:No
Enumeration Date:2016-10-06
Last Update Date:2016-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSE202993103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical