Provider Demographics
NPI:1891571311
Name:SMITH, JAMES
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3126 EMERYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:EASTOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28312-8582
Mailing Address - Country:US
Mailing Address - Phone:910-474-3192
Mailing Address - Fax:
Practice Address - Street 1:511 MARTIN LUTHER KING JR DR STE A
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-5443
Practice Address - Country:US
Practice Address - Phone:984-238-5756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YP1600X
NC101YP1600X
NCCADC-25043101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral