Provider Demographics
NPI:1538897780
Name:SMITH, KENCHELLE S
Entity type:Individual
Prefix:
First Name:KENCHELLE
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17717 VAIL ST APT 1412
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-6434
Mailing Address - Country:US
Mailing Address - Phone:346-874-0935
Mailing Address - Fax:
Practice Address - Street 1:3939 US HIGHWAY 80 E STE 223
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-3353
Practice Address - Country:US
Practice Address - Phone:972-373-4932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-15
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management