Provider Demographics
NPI:1972116580
Name:SMITH, KATHERINE J
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:J
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 1:1172 DRUMMOND LN
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28104-8036
Mailing Address - Country:US
Mailing Address - Phone:919-907-8402
Mailing Address - Fax:
Practice Address - Street 1:105 WAXHAW PROFESSIONAL PARK DR STE H
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-5018
Practice Address - Country:US
Practice Address - Phone:704-256-0305
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA15826101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty