Provider Demographics
NPI:1093552143
Name:SMITH, SHANIQUA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SHANIQUA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 WASHINGTON ST
Mailing Address - Street 2:#111
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-9998
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 WASHINGTON ST
Practice Address - Street 2:#111
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-9998
Practice Address - Country:US
Practice Address - Phone:470-485-3587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-15
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0091871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical