Provider Demographics
NPI:1215572912
Name:SMITH, SHANELLE THOMASINA (LPC)
Entity Type:Individual
Prefix:
First Name:SHANELLE
Middle Name:THOMASINA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 BOOKER AVE SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-3605
Mailing Address - Country:US
Mailing Address - Phone:770-238-6052
Mailing Address - Fax:
Practice Address - Street 1:1157 BOOKER AVE SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-3605
Practice Address - Country:US
Practice Address - Phone:770-238-6052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-18
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC006694101YP2500X
GALPC014204101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional