Provider Demographics
NPI:1154731644
Name:SMITH, KELLY
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
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 1:618 HAMAKER RD
Mailing Address - Street 2:
Mailing Address - City:MANHEIM
Mailing Address - State:PA
Mailing Address - Zip Code:17545-9134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:618 HAMAKER RD
Practice Address - Street 2:
Practice Address - City:MANHEIM
Practice Address - State:PA
Practice Address - Zip Code:17545-9134
Practice Address - Country:US
Practice Address - Phone:717-519-9740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA06610965101YS0200X
PABH000913103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool