Provider Demographics
NPI:1720762693
Name:SMITH, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:
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 1:1212 AUGUSTA WEST PKWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-1808
Mailing Address - Country:US
Mailing Address - Phone:706-826-2770
Mailing Address - Fax:706-826-2771
Practice Address - Street 1:1212 AUGUSTA WEST PKWY STE 1B
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-1808
Practice Address - Country:US
Practice Address - Phone:706-826-2770
Practice Address - Fax:706-826-2771
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-278621106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician