Provider Demographics
NPI:1659689974
Name:SMITH, KEITH CHARLES (LCSW)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:CHARLES
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 1:400 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:HILTON
Mailing Address - State:NY
Mailing Address - Zip Code:14468-1254
Mailing Address - Country:US
Mailing Address - Phone:585-392-1000
Mailing Address - Fax:
Practice Address - Street 1:400 EAST AVE
Practice Address - Street 2:
Practice Address - City:HILTON
Practice Address - State:NY
Practice Address - Zip Code:14468-1254
Practice Address - Country:US
Practice Address - Phone:585-392-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-21
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR037413-11041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool