Basic Information
Provider Information | |||||||||
NPI: | 1184266363 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SMITH | ||||||||
FirstName: | CASSANDRA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 200 OLYMPIA DRIVE APT N-3 | ||||||||
Address2: |   | ||||||||
City: | WARNER ROBINS | ||||||||
State: | GA | ||||||||
PostalCode: | 31093 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4783089653 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 120 N DUDLEY ST | ||||||||
Address2: |   | ||||||||
City: | AMERICUS | ||||||||
State: | GA | ||||||||
PostalCode: | 317093410 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4789887100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/09/2019 | ||||||||
LastUpdateDate: | 10/09/2019 | ||||||||
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 | 101Y00000X |   | GA | N |   | Behavioral Health & Social Service Providers | Counselor |   | 101YM0800X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 172V00000X |   | GA | N |   | Other Service Providers | Community Health Worker |   | 101YM0800X |   | GA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.