MEDICARE: MS. TANISHA LAVETTE 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	101YM0800X	Mental Health Counselor		GA
2	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1598603359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TANISHA LAVETTE SMITH

Provider Business Mailing Address
First Line	:	1514 LAKE PARADISE RD
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-4632
Country	:	US
Telephone Number	:	470-528-9335
Fax Number	:

Provider Business Practice Location Address
First Line	:	1514 LAKE PARADISE RD
Second Line	:
City	:	VILLA RICA
State	:	GA
Zip	:	30180-4632
Country	:	US
Telephone Number	:	470-528-9335
Fax Number	:

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

Provider Enumeration Date	:	03/23/2026
Last Update Date	:	03/23/2026

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