Provider Demographics
NPI:1194202317
Name:SMITH, DIMAYQUOAYE A (LCAS, GCDF, ICAADC)
Entity Type:Individual
Prefix:MR
First Name:DIMAYQUOAYE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCAS, GCDF, ICAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 BROOKHILL RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-4602
Mailing Address - Country:US
Mailing Address - Phone:704-284-9440
Mailing Address - Fax:
Practice Address - Street 1:501 N LAFAYETTE ST STE B
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-4477
Practice Address - Country:US
Practice Address - Phone:704-284-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20651101YA0400X, 101YM0800X
NC14447101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty