Provider Demographics
NPI:1376829622
Name:SMITH, MIRANDA S (LAPC)
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:S
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1640 POWERS FERRY RD BLDG 3
Mailing Address - Street 2:200
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-5491
Mailing Address - Country:US
Mailing Address - Phone:770-726-9589
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD BLDG 3
Practice Address - Street 2:200
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-726-9589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-01
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC003191101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor