Provider Demographics
NPI:1619053337
Name:SMITH, BLAIR KERNS (LPC, LMFT, CSOTP)
Entity Type:Individual
Prefix:MR
First Name:BLAIR
Middle Name:KERNS
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC, LMFT, CSOTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 THIMBLE SHOALS BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2573
Mailing Address - Country:US
Mailing Address - Phone:757-873-3353
Mailing Address - Fax:757-873-1810
Practice Address - Street 1:610 THIMBLE SHOALS BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2573
Practice Address - Country:US
Practice Address - Phone:757-873-3353
Practice Address - Fax:757-873-1810
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2011-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701001606101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA005412358Medicaid
VA005409691Medicaid
VA005412340Medicaid