Provider Demographics
NPI:1407514953
Name:SMITH, KYLENE (MED)
Entity Type:Individual
Prefix:
First Name:KYLENE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:KYLENE
Other - Middle Name:
Other - Last Name:GOODMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1801 LAUREL RD UNIT 201
Mailing Address - Street 2:
Mailing Address - City:LINDENWOLD
Mailing Address - State:NJ
Mailing Address - Zip Code:08021-6731
Mailing Address - Country:US
Mailing Address - Phone:267-248-5174
Mailing Address - Fax:
Practice Address - Street 1:1010 N HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19123-2334
Practice Address - Country:US
Practice Address - Phone:267-248-5174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician