Provider Demographics
NPI:1457793176
Name:SMITH, SHAMEKA RACHELLE
Entity type:Individual
Prefix:MISS
First Name:SHAMEKA
Middle Name:RACHELLE
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:PO BOX 3703
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-0038
Mailing Address - Country:US
Mailing Address - Phone:980-989-4453
Mailing Address - Fax:
Practice Address - Street 1:1550 UNION RD
Practice Address - Street 2:STE A
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-5522
Practice Address - Country:US
Practice Address - Phone:704-482-2460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-23
Last Update Date:2020-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0096811041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3232Medicaid