Provider Demographics
NPI:1093054603
Name:SMITH, KRISTINE COLLURO (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KRISTINE
Middle Name:COLLURO
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:881 PONCE DE LEON AVE NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4252
Mailing Address - Country:US
Mailing Address - Phone:404-226-7536
Mailing Address - Fax:
Practice Address - Street 1:791 VIRGINIA AVE NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30306-3630
Practice Address - Country:US
Practice Address - Phone:404-226-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0034131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical