Provider Demographics
NPI:1932706892
Name:SMITH, KRISTINE ELLECE (CSW-PIP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ELLECE
Last Name:SMITH
Suffix:
Gender:F
Credentials:CSW-PIP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561
Mailing Address - Street 2:
Mailing Address - City:WINNER
Mailing Address - State:SD
Mailing Address - Zip Code:57580-0561
Mailing Address - Country:US
Mailing Address - Phone:605-214-8486
Mailing Address - Fax:
Practice Address - Street 1:161 S. MAIN ST.
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:SD
Practice Address - Zip Code:57555
Practice Address - Country:US
Practice Address - Phone:605-214-8486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-05
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD5115104100000X
SD62731041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker