Provider Demographics
NPI:1164743662
Name:SMITH, MICHELLE C (MS, LCAS, CCS)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:C
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, LCAS, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 NASH ST NW
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27896-1127
Mailing Address - Country:US
Mailing Address - Phone:252-206-5799
Mailing Address - Fax:252-206-5778
Practice Address - Street 1:3709 NASH ST NW
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27896-1127
Practice Address - Country:US
Practice Address - Phone:252-206-5799
Practice Address - Fax:252-206-5778
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-18
Last Update Date:2015-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC733101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicaid