Provider Demographics
NPI:1710033691
Name:SMITH, KATHLEEN P (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:P
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CHADBOURNE RD FL 2
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-9645
Mailing Address - Country:US
Mailing Address - Phone:402-439-4039
Mailing Address - Fax:402-439-4035
Practice Address - Street 1:500 CHADBOURNE RD FL 2
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-9645
Practice Address - Country:US
Practice Address - Phone:402-439-4039
Practice Address - Fax:402-439-4035
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE542104100000X
CA905631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE542OtherCMSW
CA90563OtherLCSW
NE646OtherLMHP