Provider Demographics
NPI:1801496443
Name:SMITH, KIMBERLY A
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:A
Last Name:SMITH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2764 TEAKWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75075-9100
Mailing Address - Country:US
Mailing Address - Phone:972-878-8404
Mailing Address - Fax:
Practice Address - Street 1:2764 TEAKWOOD LN
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75075-9100
Practice Address - Country:US
Practice Address - Phone:972-878-8404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2025-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALH61520798101YM0800X
TX80639101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health