Provider Demographics
NPI:1497455521
Name:SMITH-STANLEY, KIMBERLY DIANE (LCMHC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DIANE
Last Name:SMITH-STANLEY
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:DIANE
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC
Mailing Address - Street 1:1329 MOUNTAIN VIEW CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:KING
Mailing Address - State:NC
Mailing Address - Zip Code:27021-7638
Mailing Address - Country:US
Mailing Address - Phone:512-803-6055
Mailing Address - Fax:
Practice Address - Street 1:640 HOLLY AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2716
Practice Address - Country:US
Practice Address - Phone:336-725-3999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX63689101YM0800X
NC18490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health