Provider Demographics
NPI:1316591696
Name:SMITH, KELLI JAE (PCLC)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JAE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-3141
Mailing Address - Country:US
Mailing Address - Phone:406-952-3772
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE STE 201
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3141
Practice Address - Country:US
Practice Address - Phone:406-952-3772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTBBH-PCLC-LIC-38715101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health