Provider Demographics
NPI:1194082818
Name:SMILEY, ODETTA (PSYD, LPC, CCMHC,MAC)
Entity type:Individual
Prefix:DR
First Name:ODETTA
Middle Name:
Last Name:SMILEY
Suffix:
Gender:F
Credentials:PSYD, LPC, CCMHC,MAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 JOSHUA CIR
Mailing Address - Street 2:
Mailing Address - City:ELLABELL
Mailing Address - State:GA
Mailing Address - Zip Code:31308-7301
Mailing Address - Country:US
Mailing Address - Phone:912-655-1811
Mailing Address - Fax:844-904-0927
Practice Address - Street 1:185 RICHARD DAVIS DR STE 102
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3978
Practice Address - Country:US
Practice Address - Phone:912-304-3051
Practice Address - Fax:844-904-0927
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-19
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
507430101YA0400X
103T00000X
GALPC004492101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1194082818OtherNPI
GA003228219AMedicaid
GA1659911063OtherNPI 2