MEDICARE: VICTOR DIMETRI SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	104100000X	Social Worker	12414	SC
2	104100000X	Social Worker	X-10412	NM
3	1041C0700X	Clinical Social Worker	180456	CA

General Provider Information

NPI Number	:	1376049890
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOR DIMETRI SMITH

Provider Business Mailing Address
First Line	:	131 BRANDIMERE DR
Second Line	:
City	:	GROVETOWN
State	:	GA
Zip	:	30813-2808
Country	:	US
Telephone Number	:	706-421-7592
Fax Number	:

Provider Business Practice Location Address
First Line	:	2424 CITY HALL LN
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-6538
Country	:	US
Telephone Number	:	843-577-5011
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2018
Last Update Date	:	10/09/2020

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Directions to “ VICTOR DIMETRI SMITH ” Practice Location

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