Provider Demographics
NPI:1902281124
Name:SMITH, KRISTA MARIE
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:MARIE
Other - Last Name:BOURDON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7412B SNELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-3204
Mailing Address - Country:US
Mailing Address - Phone:561-926-1296
Mailing Address - Fax:
Practice Address - Street 1:1820 MEMORIAL CIR
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-4539
Practice Address - Country:US
Practice Address - Phone:931-920-7333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-29
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health