Provider Demographics
NPI:1205847449
Name:SMITH, KIP (PHD)
Entity type:Individual
Prefix:
First Name:KIP
Middle Name:
Last Name:SMITH
Suffix:
Gender:
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 GREEN RD STE 218
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5719
Mailing Address - Country:US
Mailing Address - Phone:216-407-3470
Mailing Address - Fax:216-595-0088
Practice Address - Street 1:3601 GREEN RD STE 218
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5719
Practice Address - Country:US
Practice Address - Phone:216-407-3470
Practice Address - Fax:216-595-0088
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2025-04-08
Deactivation Date:2025-03-21
Deactivation Code:
Reactivation Date:2025-04-08
Provider Licenses
StateLicense IDTaxonomies
OH5006103TR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2113466Medicaid
OHSMCP78121Medicare ID - Type Unspecified
OH2113466Medicaid