Provider Demographics
NPI:1013727098
Name:SMITH, KAYLIE RENEE (ACSW)
Entity type:Individual
Prefix:
First Name:KAYLIE
Middle Name:RENEE
Last Name:SMITH
Suffix:
Gender:F
Credentials:ACSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4675 FARGO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-2407
Mailing Address - Country:US
Mailing Address - Phone:775-813-2181
Mailing Address - Fax:
Practice Address - Street 1:3511 CAMINO DEL RIO S STE 303
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4043
Practice Address - Country:US
Practice Address - Phone:619-630-7793
Practice Address - Fax:619-923-2773
Is Sole Proprietor?:No
Enumeration Date:2025-01-10
Last Update Date:2025-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW1278461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical