Provider Demographics
NPI:1871667980
Name:SMITH-MARTINEZ, KIMBERLY LISA (PHD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:LISA
Last Name:SMITH-MARTINEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 S EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-2906
Mailing Address - Country:US
Mailing Address - Phone:210-854-6786
Mailing Address - Fax:
Practice Address - Street 1:110 S EUCLID AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2906
Practice Address - Country:US
Practice Address - Phone:210-854-6786
Practice Address - Fax:708-613-5254
Is Sole Proprietor?:No
Enumeration Date:2006-11-20
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX30587103T00000X
IL071.008583103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX040555701Medicaid