Provider Demographics
NPI:1194917211
Name:SMITH, KATHLEEN WILCOX (MS, LPC, LADC, CRC)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:WILCOX
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LPC, LADC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 CLIFFMORE RD
Mailing Address - Street 2:
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06107-1121
Mailing Address - Country:US
Mailing Address - Phone:860-205-1066
Mailing Address - Fax:860-521-8291
Practice Address - Street 1:91 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06107-2509
Practice Address - Country:US
Practice Address - Phone:860-205-1066
Practice Address - Fax:860-521-8291
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000302101YA0400X
CT001086101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)