Provider Demographics
NPI:1114448164
Name:SMITH, RENEE
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
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 1:2009 BURMA RD
Mailing Address - Street 2:
Mailing Address - City:ROSSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30741-3813
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2009 BURMA RD
Practice Address - Street 2:
Practice Address - City:ROSSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30741-3813
Practice Address - Country:US
Practice Address - Phone:423-991-0034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health