Provider Demographics
NPI:1104522275
Name:SMITH, GINA NICOLE (APC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 E 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-5461
Mailing Address - Country:US
Mailing Address - Phone:912-675-2558
Mailing Address - Fax:
Practice Address - Street 1:221 EXECUTIVE CIR STE 221
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-4536
Practice Address - Country:US
Practice Address - Phone:912-465-1238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-01
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA014002101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1104522275Medicaid