Provider Demographics
NPI:1558499814
Name:SMITH, DAVID ARDELL (MA,ED)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:ARDELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA,ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:838 MINK BR
Mailing Address - Street 2:
Mailing Address - City:HAROLD
Mailing Address - State:KY
Mailing Address - Zip Code:41635-8924
Mailing Address - Country:US
Mailing Address - Phone:606-791-0075
Mailing Address - Fax:
Practice Address - Street 1:838 MINK BR
Practice Address - Street 2:
Practice Address - City:HAROLD
Practice Address - State:KY
Practice Address - Zip Code:41635-8924
Practice Address - Country:US
Practice Address - Phone:606-791-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY01882171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01882OtherCBIS # FOR FIRST STEPS