Provider Demographics
NPI:1306226014
Name:SMOCK, KIRSTEN ELISE
Entity Type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:ELISE
Last Name:SMOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 19TH AVE E
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-6322
Mailing Address - Country:US
Mailing Address - Phone:253-355-6772
Mailing Address - Fax:
Practice Address - Street 1:3214 W MCGRAW ST STE 212
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98199-3239
Practice Address - Country:US
Practice Address - Phone:206-453-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician