Provider Demographics
NPI:1942661897
Name:SMITH, KENNETH
Entity Type:Individual
Prefix:
First Name:KENNETH
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:PO BOX 725
Mailing Address - Street 2:
Mailing Address - City:EAST SANDWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02537-0725
Mailing Address - Country:US
Mailing Address - Phone:508-932-8526
Mailing Address - Fax:774-413-9810
Practice Address - Street 1:26 CAHOON RD
Practice Address - Street 2:APT A
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02532-4802
Practice Address - Country:US
Practice Address - Phone:508-932-8526
Practice Address - Fax:774-413-9810
Is Sole Proprietor?:No
Enumeration Date:2016-03-18
Last Update Date:2016-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health