Provider Demographics
NPI:1841853306
Name:SMITH, KELVIN MARTIN (CIT)
Entity type:Individual
Prefix:MR
First Name:KELVIN
Middle Name:MARTIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:CIT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 REBECCA DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5965
Mailing Address - Country:US
Mailing Address - Phone:337-661-4245
Mailing Address - Fax:337-588-4179
Practice Address - Street 1:21089 SOUTH FRONTAGE ROAD
Practice Address - Street 2:
Practice Address - City:LACASSINE
Practice Address - State:LA
Practice Address - Zip Code:70650
Practice Address - Country:US
Practice Address - Phone:337-936-9197
Practice Address - Fax:337-588-4179
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4238101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)