Provider Demographics
NPI:1336411586
Name:SMITH, KRISTIE NICOLE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIE
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:KRISTIE
Other - Middle Name:NICOLE
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1310 N HEARNE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71107-6516
Mailing Address - Country:US
Mailing Address - Phone:318-676-5111
Mailing Address - Fax:318-676-5137
Practice Address - Street 1:1310 N HEARNE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71107-6516
Practice Address - Country:US
Practice Address - Phone:318-676-5111
Practice Address - Fax:318-676-5137
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-03
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
LA4793101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health