Provider Demographics
NPI:1912413006
Name:SMITH, KIMBERLY ANN (CPST)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4269 PEARL RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-4234
Mailing Address - Country:US
Mailing Address - Phone:216-431-4131
Mailing Address - Fax:216-431-4151
Practice Address - Street 1:2554 W 25TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44113-4700
Practice Address - Country:US
Practice Address - Phone:216-781-2250
Practice Address - Fax:216-781-2252
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-27
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS001219175T00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator