Provider Demographics
NPI:1710054028
Name:SMITH, JR., KENNETH RAY (MDIV, MA)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:RAY
Last Name:SMITH, JR.
Suffix:
Gender:M
Credentials:MDIV, MA
Other - Prefix:MR
Other - First Name:KENNETH
Other - Middle Name:R
Other - Last Name:SMITH, M.DIV., M.A.
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MDIV, MA
Mailing Address - Street 1:2012 NE 65TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6934
Mailing Address - Country:US
Mailing Address - Phone:206-523-3202
Mailing Address - Fax:206-367-0919
Practice Address - Street 1:2012 NE 65TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-6934
Practice Address - Country:US
Practice Address - Phone:206-523-3202
Practice Address - Fax:206-367-0919
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF00001684101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health