Provider Demographics
NPI:1164111910
Name:SMITH, VICTORIA MARSHELLE
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:MARSHELLE
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 1:7104 MOYE DR
Mailing Address - Street 2:
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-7529
Mailing Address - Country:US
Mailing Address - Phone:678-662-5428
Mailing Address - Fax:
Practice Address - Street 1:7104 MOYE DR
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-7529
Practice Address - Country:US
Practice Address - Phone:678-662-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician