Basic Information
| Provider Information | |||||||||
| NPI: | 1295289973 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | ROSE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARTER | ||||||||
| OtherFirstName: | KAYLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 232 E 82ND ST. | ||||||||
| Address2: | |||||||||
| City: | NEWAYGO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49337 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 232 E 82ND ST. | ||||||||
| Address2: | |||||||||
| City: | NEWAYGO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2316521780 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2016 | ||||||||
| LastUpdateDate: | 04/03/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 04/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 6801105010 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.