Provider Demographics
NPI:1295985745
Name:SMITH, KELLY NICOLE (LICSW, LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LICSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 WESTOVER DR SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20020-3719
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3181 WESTOVER DR SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20020-3719
Practice Address - Country:US
Practice Address - Phone:404-693-6003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-21
Last Update Date:2014-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0039001041C0700X
DCLC500795501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical