Provider Demographics
NPI:1700463809
Name:SMITH, KIA C (MREL, PCMHT)
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:MREL, PCMHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 HIGHWAY 51 N
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:39601-2337
Mailing Address - Country:US
Mailing Address - Phone:601-823-2345
Mailing Address - Fax:601-833-3752
Practice Address - Street 1:620 HIGHWAY 51 N
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2337
Practice Address - Country:US
Practice Address - Phone:601-823-2345
Practice Address - Fax:601-833-3752
Is Sole Proprietor?:No
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health