Provider Demographics
NPI:1801523956
Name:SMITH, KELLY SUSANNE
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUSANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:S
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2603 COUNTY ROAD 7540
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-6366
Mailing Address - Country:US
Mailing Address - Phone:806-281-4566
Mailing Address - Fax:
Practice Address - Street 1:2603 COUNTY ROAD 7540
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-6366
Practice Address - Country:US
Practice Address - Phone:806-281-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX202111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty