Provider Demographics
NPI:1558493056
Name:SMITH, KIM MARIE (LCSW, LMFT)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3266 MALLARD COVE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2883
Mailing Address - Country:US
Mailing Address - Phone:260-436-5986
Mailing Address - Fax:260-436-1859
Practice Address - Street 1:3266 MALLARD COVE LN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2883
Practice Address - Country:US
Practice Address - Phone:260-436-5986
Practice Address - Fax:260-436-1859
Is Sole Proprietor?:No
Enumeration Date:2007-03-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34002738A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000200512OtherANTHEM BLUE CROSS BLUE SH
090831OtherMHN
IN000000200512OtherANTHEM BLUE CROSS BLUE SH