Provider Demographics
NPI:1043274186
Name:SMITH, KIM R (LMHC, LPC)
Entity type:Individual
Prefix:MS
First Name:KIM
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMHC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:908 LAKE ELSIE DR
Mailing Address - Street 2:
Mailing Address - City:TAVARES
Mailing Address - State:FL
Mailing Address - Zip Code:32778-4978
Mailing Address - Country:US
Mailing Address - Phone:352-409-6540
Mailing Address - Fax:
Practice Address - Street 1:210 N HIGHWAY 27 STE 4
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2411
Practice Address - Country:US
Practice Address - Phone:352-708-6283
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7880101YP2500X
FLMH8094101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL766501600Medicaid
FLZ090MOtherBLUE CROSS BLUE SHIELD #