Provider Demographics
NPI:1326359878
Name:SMITH, MELISSA (ATC, LAT, OTC, MS)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ATC, LAT, OTC, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 LENOX PARK BLVD NE
Mailing Address - Street 2:APT 2302
Mailing Address - City:BROOKHAVEN
Mailing Address - State:GA
Mailing Address - Zip Code:30319-5826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:59 EXECUTIVE PARK S
Practice Address - Street 2:SUITE 2000
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30329-2208
Practice Address - Country:US
Practice Address - Phone:404-778-3350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT001743174400000X
246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist