Provider Demographics
NPI:1811967631
Name:SMITH, KEITH R (PMHNP, BC)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:R
Last Name:SMITH
Suffix:
Gender:M
Credentials:PMHNP, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10906 ROCKY TRL
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78249-4133
Mailing Address - Country:US
Mailing Address - Phone:210-912-8547
Mailing Address - Fax:
Practice Address - Street 1:2200 BERGQUIST DR
Practice Address - Street 2:SUITE 1
Practice Address - City:LACKLAND A F B
Practice Address - State:TX
Practice Address - Zip Code:78236-9907
Practice Address - Country:US
Practice Address - Phone:210-292-6225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX530772363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health