Provider Demographics
NPI:1578643342
Name:SMITH, KEVIN JEFFERY (LMFT)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:JEFFERY
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21395 JOHN MILLESS DR. #400
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374
Mailing Address - Country:US
Mailing Address - Phone:763-424-1888
Mailing Address - Fax:763-424-7288
Practice Address - Street 1:21395 JOHN MILLESS DR. #400
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374
Practice Address - Country:US
Practice Address - Phone:763-424-1888
Practice Address - Fax:763-424-7288
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1269106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN258615100Medicaid