Provider Demographics
NPI:1104266014
Name:SMITH, KELLI JEAN (LISW)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:JEAN
Other - Last Name:CASE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:128 PLAZA CIR
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50701-5139
Mailing Address - Country:US
Mailing Address - Phone:193-774-3081
Mailing Address - Fax:319-435-4155
Practice Address - Street 1:128 PLAZA CIR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-5139
Practice Address - Country:US
Practice Address - Phone:319-774-3081
Practice Address - Fax:319-435-4155
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0079601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical