Provider Demographics
NPI:1073337986
Name:SMITH, CHANTIA
Entity type:Individual
Prefix:
First Name:CHANTIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71270-1285
Mailing Address - Country:US
Mailing Address - Phone:318-550-6743
Mailing Address - Fax:
Practice Address - Street 1:910 S VIENNA ST STE 7
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-5864
Practice Address - Country:US
Practice Address - Phone:318-224-9200
Practice Address - Fax:318-224-9201
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator