MEDICARE: DR. ODETTA SMILEY PSYD, LPC, CCMHC,MAC

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	507430
2	103T00000X	Psychologist
3	101YP2500X	Professional Counselor	LPC004492	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1194082818	OTHER	GA	NPI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	1659911063	OTHER	GA	NPI 2

General Provider Information

NPI Number	:	1194082818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ODETTA SMILEY PSYD, LPC, CCMHC,MAC

Provider Business Mailing Address
First Line	:	20 JOSHUA CIR
Second Line	:
City	:	ELLABELL
State	:	GA
Zip	:	31308-7301
Country	:	US
Telephone Number	:	912-655-1811
Fax Number	:	844-904-0927

Provider Business Practice Location Address
First Line	:	185 RICHARD DAVIS DR STE 102
Second Line	:
City	:	RICHMOND HILL
State	:	GA
Zip	:	31324-3978
Country	:	US
Telephone Number	:	912-304-3051
Fax Number	:	844-904-0927

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

Provider Enumeration Date	:	04/19/2012
Last Update Date	:	01/26/2024

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