Provider Demographics
NPI:1568653913
Name:SMITH, KIMBERLY K
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:K
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 1:1200 E BROADWAY
Mailing Address - Street 2:STEPHENS COLLEGE, STAMPER COMMONS
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65215-0001
Mailing Address - Country:US
Mailing Address - Phone:573-876-7157
Mailing Address - Fax:
Practice Address - Street 1:1200 E BROADWAY
Practice Address - Street 2:STEPHENS COLLEGE, STAMPER COMMONS
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65215-0001
Practice Address - Country:US
Practice Address - Phone:573-876-7157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW003197101Y00000X, 101YA0400X, 101YM0800X, 101YP2500X, 101YS0200X, 1041C0700X, 1041S0200X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist