Provider Demographics
NPI:1306470406
Name:SMITH, DAVID (MBA, MHRM)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MBA, MHRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:556 HARVICK CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4460
Mailing Address - Country:US
Mailing Address - Phone:678-755-2554
Mailing Address - Fax:
Practice Address - Street 1:556 HARVICK CIR
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4460
Practice Address - Country:US
Practice Address - Phone:678-755-2554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-27
Last Update Date:2020-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA101YP1600X, 101YM0800X
101YP2500X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoralGroup - Single Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician