Healthcare Provider Details

I. General information

NPI: 1205730447
Provider Name (Legal Business Name): SHAQUAVIA KIANA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 SPRING ST APT 201
LAGRANGE GA
30240-1791
US

IV. Provider business mailing address

90 SPRING ST APT 201
LAGRANGE GA
30240-1791
US

V. Phone/Fax

Practice location:
  • Phone: 762-308-1752
  • Fax:
Mailing address:
  • Phone: 762-308-1752
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number26-2852588
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: