Provider Demographics
NPI:1831706704
Name:MICKENS-SMITH, KENYAH MONET (LMFT, LCAS)
Entity type:Individual
Prefix:
First Name:KENYAH
Middle Name:MONET
Last Name:MICKENS-SMITH
Suffix:
Gender:F
Credentials:LMFT, LCAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7745 BALLANTYNE COMMONS PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-5056
Mailing Address - Country:US
Mailing Address - Phone:704-995-0342
Mailing Address - Fax:704-943-0707
Practice Address - Street 1:1300 BAXTER ST STE 421
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3026
Practice Address - Country:US
Practice Address - Phone:704-995-0342
Practice Address - Fax:704-943-0707
Is Sole Proprietor?:No
Enumeration Date:2020-09-25
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
2490106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2490OtherLMFT