Provider Demographics
NPI:1609921279
Name:SMITH, KENNETH BRACE (LCSW)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:BRACE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:563 PLEASANT VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:NY
Mailing Address - Zip Code:13073-9216
Mailing Address - Country:US
Mailing Address - Phone:607-330-0398
Mailing Address - Fax:
Practice Address - Street 1:1062 STATE ROUTE 38
Practice Address - Street 2:
Practice Address - City:OWEGO
Practice Address - State:NY
Practice Address - Zip Code:13827
Practice Address - Country:US
Practice Address - Phone:607-687-4000
Practice Address - Fax:607-687-6396
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY069846-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY069846-1OtherLCSW LICENSE NUMBER
NY00618162Medicaid
NY00618162Medicaid