Basic Information
Provider Information | |||||||||
NPI: | 1023409232 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | CARLA | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NANCOO | ||||||||
OtherFirstName: | CARLA | ||||||||
OtherMiddleName: | P | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4947 | ||||||||
Address2: |   | ||||||||
City: | MACON | ||||||||
State: | GA | ||||||||
PostalCode: | 312084947 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783012362 | ||||||||
FaxNumber: | 4783012272 | ||||||||
Practice Location | |||||||||
Address1: | 105 COLLIER RD | ||||||||
Address2: | SUITE 4040 | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 30309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783015930 | ||||||||
FaxNumber: | 4783015932 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2015 | ||||||||
LastUpdateDate: | 12/30/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | CSW005381 | GA | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | MFT001383 | GA | N |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
No ID Information.