Provider Demographics
NPI:1538720578
Name:SMITH, KRISTYN COLLETTE
Entity type:Individual
Prefix:
First Name:KRISTYN
Middle Name:COLLETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KRISTYN
Other - Middle Name:COLETTE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ACSW
Mailing Address - Street 1:2640 INDUSTRY WAY STE B
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-4285
Mailing Address - Country:US
Mailing Address - Phone:310-627-4525
Mailing Address - Fax:
Practice Address - Street 1:9808 VENICE BLVD STE 505
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90232-6818
Practice Address - Country:US
Practice Address - Phone:310-945-3350
Practice Address - Fax:310-945-3356
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CA98528101YM0800X, 104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker