Provider Demographics
NPI:1235705393
Name:SMITH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DONAHUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 UNIVERSITY CITY BLVD
Mailing Address - Street 2:
Mailing Address - City:BLACKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24060-2706
Mailing Address - Country:US
Mailing Address - Phone:540-961-8300
Mailing Address - Fax:540-961-8465
Practice Address - Street 1:700 UNIVERSITY CITY BLVD
Practice Address - Street 2:
Practice Address - City:BLACKSBURG
Practice Address - State:VA
Practice Address - Zip Code:24060-2706
Practice Address - Country:US
Practice Address - Phone:540-961-8300
Practice Address - Fax:540-961-8465
Is Sole Proprietor?:No
Enumeration Date:2021-05-31
Last Update Date:2021-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040129331041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical