Provider Demographics
NPI:1972845667
Name:SMITH, RANDALL E (MDIV, LMFT)
Entity type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:MDIV, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2210 GOLDSMITH LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-1038
Mailing Address - Country:US
Mailing Address - Phone:502-558-0259
Mailing Address - Fax:888-972-8341
Practice Address - Street 1:9103 TRENTHAM LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40242-3383
Practice Address - Country:US
Practice Address - Phone:502-558-0259
Practice Address - Fax:888-972-8341
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0724106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100265880Medicaid