Healthcare Provider Details

I. General information

NPI: 1750779237
Provider Name (Legal Business Name): LANA SMITH CSW006563
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 11/04/2020
Certification Date: 11/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1145 PINE LAKE DR
GRAYSON GA
30017-7926
US

IV. Provider business mailing address

1105 GREGG HWY
AIKEN SC
29801-6341
US

V. Phone/Fax

Practice location:
  • Phone: 404-522-3100
  • Fax:
Mailing address:
  • Phone: 803-649-1900
  • Fax: 803-643-2926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: