Healthcare Provider Details

I. General information

NPI: 1104573146
Provider Name (Legal Business Name): LAVORICE SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2022
Last Update Date: 02/05/2026
Certification Date: 02/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 HIGHLAND AVE # 100
WINSTON SALEM NC
27101-4304
US

IV. Provider business mailing address

284 EXECUTIVE PARK DR STE 100
CONCORD NC
28025-1833
US

V. Phone/Fax

Practice location:
  • Phone: 336-607-8523
  • Fax:
Mailing address:
  • Phone: 704-939-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCADC-25140
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: