Healthcare Provider Details

I. General information

NPI: 1174352264
Provider Name (Legal Business Name): SHELBY NICOLE SMITH NCC, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2024
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NEXTON SQUARE DR
SUMMERVILLE SC
29486-7915
US

IV. Provider business mailing address

619 ALWYN BLVD
SUMMERVILLE SC
29485-4091
US

V. Phone/Fax

Practice location:
  • Phone: 843-647-3916
  • Fax:
Mailing address:
  • Phone: 706-832-2707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12459
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: