Provider Demographics
NPI:1942756739
Name:SMITH, KENOYA (LCSW-A, LP, CDCA)
Entity Type:Individual
Prefix:
First Name:KENOYA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW-A, LP, CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3383 HENDERSON DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-5231
Mailing Address - Country:US
Mailing Address - Phone:912-980-7911
Mailing Address - Fax:
Practice Address - Street 1:3383 HENDERSON DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5231
Practice Address - Country:US
Practice Address - Phone:912-980-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH130972101YA0400X
NCP0107941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)