MEDICARE: NICOLE SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	CADC-27093	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1810	OTHER	NC	PRACTICE USE IN NORTH CAROLINA

General Provider Information

NPI Number	:	1063158525
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE SMITH

Provider Business Mailing Address
First Line	:	246 W KITTY HAWK RD
Second Line	:
City	:	KITTY HAWK
State	:	NC
Zip	:	27949-4707
Country	:	US
Telephone Number	:	252-207-9511
Fax Number	:

Provider Business Practice Location Address
First Line	:	2400 N CROATAN HWY STE G
Second Line	:
City	:	KILL DEVIL HILLS
State	:	NC
Zip	:	27948-9356
Country	:	US
Telephone Number	:	252-207-9511
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/09/2022
Last Update Date	:	05/09/2022

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Directions to “ NICOLE SMITH ” Practice Location

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