Provider Demographics
NPI:1528587235
Name:SMITH, TRACI A (LISW, LCSW)
Entity type:Individual
Prefix:
First Name:TRACI
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:LISW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1207 WADING POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:HUGER
Mailing Address - State:SC
Mailing Address - Zip Code:29450-9805
Mailing Address - Country:US
Mailing Address - Phone:843-693-7303
Mailing Address - Fax:
Practice Address - Street 1:2100 CHARLIE HALL BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5832
Practice Address - Country:US
Practice Address - Phone:843-852-4100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-13
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0174321041C0700X
SC166231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1760596480Medicaid