=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760123657
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KHALILIAH KENDRA SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2022
-----------------------------------------------------
Last Update Date | 04/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1005 MILSTEAD AVE NE STE 103
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30012-4509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-860-8549
-----------------------------------------------------
Fax | 866-210-1269
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1705 DRUIDS CT SE
-----------------------------------------------------
City | CONYERS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30013-2979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-851-8703
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | 12841
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------