Provider Demographics
NPI:1649578204
Name:SMITH, KIMMIE (MS)
Entity type:Individual
Prefix:
First Name:KIMMIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KRISSY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 1231
Mailing Address - Street 2:
Mailing Address - City:WRANGELL
Mailing Address - State:AK
Mailing Address - Zip Code:99929-1231
Mailing Address - Country:US
Mailing Address - Phone:907-874-2373
Mailing Address - Fax:
Practice Address - Street 1:817 ZIMOVIA HWY
Practice Address - Street 2:APT 2
Practice Address - City:WRANGELL
Practice Address - State:AK
Practice Address - Zip Code:99929
Practice Address - Country:US
Practice Address - Phone:907-305-0985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-07
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK147993101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional