Provider Demographics
NPI:1760813752
Name:SMITH, KEVIN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1708 TRAWICK RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-3897
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1708 TRAWICK RD
Practice Address - Street 2:SUITE 101
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27604-3897
Practice Address - Country:US
Practice Address - Phone:919-896-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-02
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9030A106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist