Healthcare Provider Details

I. General information

NPI: 1922263326
Provider Name (Legal Business Name): SMITH COUNSELING CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 N WILEY AVE
DONALSONVILLE GA
39845-1120
US

IV. Provider business mailing address

804 N WILEY AVE
DONALSONVILLE GA
39845-1120
US

V. Phone/Fax

Practice location:
  • Phone: 229-524-8994
  • Fax: 229-524-1272
Mailing address:
  • Phone: 229-524-8994
  • Fax: 229-524-1272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC004048
License Number StateGA

VIII. Authorized Official

Name: GARY W SMITH
Title or Position: COUNSELOR
Credential: PHD
Phone: 229-524-8994