Provider Demographics
NPI:1669743340
Name:SMITH, KELLY (PCW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:PCW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 S. HUMAHUACA
Mailing Address - Street 2:
Mailing Address - City:PAHRUMP
Mailing Address - State:NV
Mailing Address - Zip Code:89048
Mailing Address - Country:US
Mailing Address - Phone:775-751-7406
Mailing Address - Fax:775-751-7409
Practice Address - Street 1:240 S. HUMAHUACA
Practice Address - Street 2:
Practice Address - City:PAHRUMP
Practice Address - State:NV
Practice Address - Zip Code:89048
Practice Address - Country:US
Practice Address - Phone:775-751-7406
Practice Address - Fax:775-751-7409
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-26
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health