Provider Demographics
NPI:1811369903
Name:SMITH, ELLIE
Entity Type:Individual
Prefix:
First Name:ELLIE
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 1:425 BROADWAY ST
Mailing Address - Street 2:202
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-0713
Mailing Address - Country:US
Mailing Address - Phone:270-442-8039
Mailing Address - Fax:
Practice Address - Street 1:425 BROADWAY ST
Practice Address - Street 2:202
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-0713
Practice Address - Country:US
Practice Address - Phone:270-442-8039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical