Provider Demographics
NPI:1376610964
Name:SMYTH, KEVIN GERARD (MED, PCC)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:GERARD
Last Name:SMYTH
Suffix:
Gender:M
Credentials:MED, PCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 44
Mailing Address - Street 2:
Mailing Address - City:AMESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45711-0044
Mailing Address - Country:US
Mailing Address - Phone:740-448-2228
Mailing Address - Fax:
Practice Address - Street 1:12788 NEW ENGLAND RD
Practice Address - Street 2:
Practice Address - City:AMESVILLE
Practice Address - State:OH
Practice Address - Zip Code:45711-9327
Practice Address - Country:US
Practice Address - Phone:740-448-2228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHE-0008310101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health