Provider Demographics
NPI:1740434984
Name:SMITH, KIMBERLY BEATHAM
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BEATHAM
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 1:1021 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:VEAZIE
Mailing Address - State:ME
Mailing Address - Zip Code:04401-7061
Mailing Address - Country:US
Mailing Address - Phone:207-992-7990
Mailing Address - Fax:
Practice Address - Street 1:50 MOODY ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1536
Practice Address - Country:US
Practice Address - Phone:207-373-4380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3458101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical