Provider Demographics
NPI:1780852442
Name:SMITH, KYLE S (LBSW)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:S
Last Name:SMITH
Suffix:
Gender:M
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7191 FAWN DR
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-9335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6051 FRANKFORT HWY STE 200
Practice Address - Street 2:
Practice Address - City:BENZONIA
Practice Address - State:MI
Practice Address - Zip Code:49616-9651
Practice Address - Country:US
Practice Address - Phone:877-398-2013
Practice Address - Fax:231-882-2360
Is Sole Proprietor?:No
Enumeration Date:2008-02-15
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802081145104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802081145OtherSTATE OF MICHIGAN LICENSE