Healthcare Provider Details

I. General information

NPI: 1841536976
Provider Name (Legal Business Name): MEHALA A SMITH M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2012
Last Update Date: 12/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 GWINNETT DR
LAWRENCEVILLE GA
30046-8444
US

IV. Provider business mailing address

508 COBBLESTONE CREEK CT
MABLETON GA
30126-2657
US

V. Phone/Fax

Practice location:
  • Phone: 770-339-2395
  • Fax: 678-990-3997
Mailing address:
  • Phone: 404-593-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW004494
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: