Provider Demographics
NPI:1912477647
Name:SMITH, KELLEY JENEAN
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:JENEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MINNESOTA AVENUE
Mailing Address - Street 2:3946 MINNESOTA AVENUE NE
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-6044
Mailing Address - Country:US
Mailing Address - Phone:202-398-8683
Mailing Address - Fax:202-548-8600
Practice Address - Street 1:MINNESOTA AVENUE
Practice Address - Street 2:3946 MINNESOTA AVENUE NE
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-6044
Practice Address - Country:US
Practice Address - Phone:202-398-8683
Practice Address - Fax:202-548-8600
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701007939101YP2500X
DCPRC14827101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional