Provider Demographics
NPI:1609586155
Name:SMITH, KYNESHA (LISW-CP)
Entity Type:Individual
Prefix:
First Name:KYNESHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW-CP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:MAYESVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29104-0248
Mailing Address - Country:US
Mailing Address - Phone:404-981-5004
Mailing Address - Fax:
Practice Address - Street 1:7901 4TH ST N STE 4000
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4305
Practice Address - Country:US
Practice Address - Phone:404-981-5004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-24
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC13386104100000X
SC15703104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker