Provider Demographics
NPI:1376896803
Name:SMITH, KELLY CRAGHILL FAGERBURG (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:CRAGHILL FAGERBURG
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 23RD ST S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-3707
Mailing Address - Country:US
Mailing Address - Phone:701-297-7540
Mailing Address - Fax:701-297-6439
Practice Address - Street 1:1308 23RD ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-3707
Practice Address - Country:US
Practice Address - Phone:701-297-7540
Practice Address - Fax:701-297-6439
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND473103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND17313Medicaid
ND17313Medicaid