Provider Demographics
NPI:1710731468
Name:SMITH, ANNA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4401 MACKENZIE PL
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-5109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11824 RANSUM DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2802
Practice Address - Country:US
Practice Address - Phone:502-908-9410
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY280657101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health