Provider Demographics
NPI:1275124109
Name:SMYLIE, KENNETH LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:LEE
Last Name:SMYLIE
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8711 NW 40TH CIR
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32653-0078
Mailing Address - Country:US
Mailing Address - Phone:352-215-8844
Mailing Address - Fax:
Practice Address - Street 1:8711 NW 40TH CIR
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32653-0078
Practice Address - Country:US
Practice Address - Phone:352-215-8844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMT1828101YP1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty