Provider Demographics
NPI:1568864742
Name:SMITH, KENNETH (MS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:522 GLENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:NEW BOSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45662-5505
Mailing Address - Country:US
Mailing Address - Phone:740-354-0270
Mailing Address - Fax:740-354-0280
Practice Address - Street 1:522 GLENWOOD AVE
Practice Address - Street 2:
Practice Address - City:NEW BOSTON
Practice Address - State:OH
Practice Address - Zip Code:45662-5505
Practice Address - Country:US
Practice Address - Phone:740-354-0270
Practice Address - Fax:740-354-0280
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOU1023241103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool