Provider Demographics
NPI:1013148394
Name:SMITH, ALLEN (MSW)
Entity type:Individual
Prefix:
First Name:ALLEN
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 E 6TH ST
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42276-1917
Mailing Address - Country:US
Mailing Address - Phone:270-726-3629
Mailing Address - Fax:270-726-3115
Practice Address - Street 1:237 E 6TH ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:KY
Practice Address - Zip Code:42276-1917
Practice Address - Country:US
Practice Address - Phone:270-726-3629
Practice Address - Fax:270-726-3115
Is Sole Proprietor?:No
Enumeration Date:2009-08-04
Last Update Date:2009-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30604011Medicaid