Provider Demographics
NPI:1437905221
Name:SMITH, KENNETH LEROY SR (LPC014651)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEROY
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:LPC014651
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1838 REDMOND CIR NW STE E
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1379
Mailing Address - Country:US
Mailing Address - Phone:706-270-5022
Mailing Address - Fax:762-320-5365
Practice Address - Street 1:332 HASTY RD NE
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-7795
Practice Address - Country:US
Practice Address - Phone:762-357-4921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-24
Last Update Date:2024-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC14651101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health