Provider Demographics
NPI:1124113261
Name:SMITH, KEVIN J (PHD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:J
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 MAYFIELD RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-2602
Mailing Address - Country:US
Mailing Address - Phone:216-291-4000
Mailing Address - Fax:216-291-4111
Practice Address - Street 1:5001 MAYFIELD RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-2602
Practice Address - Country:US
Practice Address - Phone:216-291-4000
Practice Address - Fax:216-291-4111
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4780103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000190318OtherANTHEM
OH0964256Medicaid
OH6100371OtherEVERCARE
OH000000190318OtherANTHEM