Provider Demographics
NPI:1043777345
Name:SMITH, KEIQUANAE TATAYANA
Entity Type:Individual
Prefix:
First Name:KEIQUANAE
Middle Name:TATAYANA
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 1:55 SERGEANT PRENTISS DR STE 102
Mailing Address - Street 2:
Mailing Address - City:NATCHEZ
Mailing Address - State:MS
Mailing Address - Zip Code:39120-4791
Mailing Address - Country:US
Mailing Address - Phone:601-304-5567
Mailing Address - Fax:
Practice Address - Street 1:55 SERGEANT PRENTISS DR STE 102
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4791
Practice Address - Country:US
Practice Address - Phone:601-304-5567
Practice Address - Fax:601-304-5697
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-23
Last Update Date:2019-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health