Provider Demographics
NPI:1912500513
Name:SMITH, KEENAN RAY TOM
Entity Type:Individual
Prefix:
First Name:KEENAN
Middle Name:RAY TOM
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:776 S STATE ST STE 107
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5858
Mailing Address - Country:US
Mailing Address - Phone:707-463-4915
Mailing Address - Fax:
Practice Address - Street 1:776 S STATE ST STE 107
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5858
Practice Address - Country:US
Practice Address - Phone:707-463-4915
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-17
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor