Provider Demographics
NPI:1699073510
Name:SMITH, PHILLIP (LPC, RASAC II)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC, RASAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 TRACY AVE
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64109-1529
Mailing Address - Country:US
Mailing Address - Phone:816-753-4011
Mailing Address - Fax:
Practice Address - Street 1:2900 TRACY AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64109-1529
Practice Address - Country:US
Practice Address - Phone:816-753-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009038191101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional