Provider Demographics
NPI:1710044136
Name:SMITH, MARY KENDALL (LISW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KENDALL
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:KENDALL
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LISW
Mailing Address - Street 1:5564 WILSON MILLS ROAD, SUITE 201
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44143
Mailing Address - Country:US
Mailing Address - Phone:440-473-9037
Mailing Address - Fax:440-461-1047
Practice Address - Street 1:5564 WILSON MILLS RD STE 201
Practice Address - Street 2:
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44143-3265
Practice Address - Country:US
Practice Address - Phone:440-473-9037
Practice Address - Fax:440-461-1047
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI05000461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical