Provider Demographics
NPI:1295397495
Name:SMITH, KEVIN JAMES (LMSW)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1076 E RUBICON DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-5279
Mailing Address - Country:US
Mailing Address - Phone:208-954-1113
Mailing Address - Fax:
Practice Address - Street 1:1076 E RUBICON DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83716-5279
Practice Address - Country:US
Practice Address - Phone:208-954-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-08
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker