Provider Demographics
NPI:1013407006
Name:SMITH, KIMRON (MA)
Entity type:Individual
Prefix:
First Name:KIMRON
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6014 ALYCIA NIKOLE LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-4357
Mailing Address - Country:US
Mailing Address - Phone:318-820-1985
Mailing Address - Fax:
Practice Address - Street 1:7550 PINES ROAD SUITE 1115
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71129
Practice Address - Country:US
Practice Address - Phone:318-683-4086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$Medicaid