Provider Demographics
NPI:1841311248
Name:SMITH, KEN D (MA, LCMHC, LADC)
Entity type:Individual
Prefix:MR
First Name:KEN
Middle Name:D
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA, LCMHC, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 UNION ST
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:VT
Mailing Address - Zip Code:05733-1127
Mailing Address - Country:US
Mailing Address - Phone:802-247-3136
Mailing Address - Fax:
Practice Address - Street 1:3 UNION ST
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:VT
Practice Address - Zip Code:05733-1127
Practice Address - Country:US
Practice Address - Phone:802-247-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT000401101YA0400X
VT0680000419101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT1007742Medicaid
VT49976OtherPROVIDER NUMBER