Provider Demographics
NPI:1992431480
Name:SMITH, SUSAN KELLAS (QMHP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:KELLAS
Last Name:SMITH
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:LOVETT
Other - Last Name:KELLAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:QMHP
Mailing Address - Street 1:200 E BROAD ST STE 300
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2891
Mailing Address - Country:US
Mailing Address - Phone:800-805-6989
Mailing Address - Fax:864-558-8511
Practice Address - Street 1:500 PEGASUS COURT BUSINESS CENTER STE 500
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:864-558-8511
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0733004211101YM0800X
VA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health