Provider Demographics
NPI:1518601657
Name:SMITH, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15490 CIVIC DR STE 103
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-2382
Mailing Address - Country:US
Mailing Address - Phone:442-484-6572
Mailing Address - Fax:
Practice Address - Street 1:15490 CIVIC DR STE 103
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2382
Practice Address - Country:US
Practice Address - Phone:442-484-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician