Provider Demographics
NPI:1356788848
Name:SMITH, KIMBERLY ERIN
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ERIN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 52148
Mailing Address - Street 2:
Mailing Address - City:AKIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99552-0148
Mailing Address - Country:US
Mailing Address - Phone:907-765-7393
Mailing Address - Fax:
Practice Address - Street 1:829 CHIEF EDDIE HOFFMAN HIGHWAY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMH0150Medicaid