Provider Demographics
NPI:1942951934
Name:SMITH, KEVIN J (LGPC, CAC-AD, MS)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:LGPC, CAC-AD, MS
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 748465
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-8465
Mailing Address - Country:US
Mailing Address - Phone:855-284-7483
Mailing Address - Fax:
Practice Address - Street 1:400 REDLAND CT
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-3290
Practice Address - Country:US
Practice Address - Phone:410-701-2456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-12
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC2199101YA0400X
MDLGP13493101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)