Healthcare Provider Details

I. General information

NPI: 1174782452
Provider Name (Legal Business Name): MICHELE S SMITH PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 05/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 CORPORATE CENTER DR SUITE 200
MORROW GA
30260-4180
US

IV. Provider business mailing address

1000 CORPORATE CENTER DR STE 200
MORROW GA
30260-4129
US

V. Phone/Fax

Practice location:
  • Phone: 770-968-6380
  • Fax: 770-968-6465
Mailing address:
  • Phone: 770-968-6464
  • Fax: 770-968-6465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFT001178
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC43092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: