Provider Demographics
NPI:1215683412
Name:SMITH, SYNTHIA ANNA
Entity type:Individual
Prefix:
First Name:SYNTHIA
Middle Name:ANNA
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 1:2355 VILLAGE CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-8763
Mailing Address - Country:US
Mailing Address - Phone:678-820-8494
Mailing Address - Fax:
Practice Address - Street 1:2355 VILLAGE CENTRE DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-8763
Practice Address - Country:US
Practice Address - Phone:678-820-8494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC12678101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty