Healthcare Provider Details

I. General information

NPI: 1861152969
Provider Name (Legal Business Name): LIKEDRA SHZNELLE SMITH LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2021
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 PEACHTREE ST NE STE 110
ATLANTA GA
30309-3005
US

IV. Provider business mailing address

1401 PEACHTREE ST NE STE 110
ATLANTA GA
30309-3005
US

V. Phone/Fax

Practice location:
  • Phone: 770-389-8100
  • Fax:
Mailing address:
  • Phone: 678-761-4154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPC008617
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC014995
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: