Provider Demographics
NPI:1649809690
Name:SMITH, KYLEN ELIZABETH (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KYLEN
Middle Name:ELIZABETH
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 SHAKER RUN
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-2453
Mailing Address - Country:US
Mailing Address - Phone:518-764-2059
Mailing Address - Fax:
Practice Address - Street 1:30 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12203-1410
Practice Address - Country:US
Practice Address - Phone:518-453-6710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
14342287235Z00000X
NY030076235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030076OtherNYS OFFICE OF THE PROFESSIONS
14342287OtherASHA