Provider Demographics
NPI:1659664910
Name:SMITH, KAITLIN M (PC)
Entity type:Individual
Prefix:
First Name:KAITLIN
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 N PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:OH
Mailing Address - Zip Code:43402-2021
Mailing Address - Country:US
Mailing Address - Phone:419-308-5383
Mailing Address - Fax:
Practice Address - Street 1:1045 KLOTZ RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-4820
Practice Address - Country:US
Practice Address - Phone:419-352-7588
Practice Address - Fax:419-354-4977
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHC0900482101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC0900482OtherSTATE OF OHIO COUNSELOR, SOCIAL WORKER, MARRIAGE & FAMILY THERAPIST BOARD