Provider Demographics
NPI:1548335409
Name:SMITH, W KELLAR (MA)
Entity type:Individual
Prefix:MR
First Name:W
Middle Name:KELLAR
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:356 BRUIN RD
Mailing Address - Street 2:
Mailing Address - City:PETROLIA
Mailing Address - State:PA
Mailing Address - Zip Code:16050
Mailing Address - Country:US
Mailing Address - Phone:724-753-2650
Mailing Address - Fax:
Practice Address - Street 1:1022 A N MAIN ST
Practice Address - Street 2:AVADA BLDG 2ND FLOOR
Practice Address - City:BUTLER
Practice Address - State:PA
Practice Address - Zip Code:16001
Practice Address - Country:US
Practice Address - Phone:724-283-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS007665L103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01972890Medicaid
PASM694573Medicare ID - Type Unspecified