Provider Demographics
NPI:1376966374
Name:SMITH, PORTIA (LPC, CRC)
Entity Type:Individual
Prefix:
First Name:PORTIA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC, CRC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 COVINGTON CV
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:GA
Mailing Address - Zip Code:31008-9525
Mailing Address - Country:US
Mailing Address - Phone:478-952-6703
Mailing Address - Fax:
Practice Address - Street 1:508 COVINGTON CV
Practice Address - Street 2:
Practice Address - City:BYRON
Practice Address - State:GA
Practice Address - Zip Code:31008-9525
Practice Address - Country:US
Practice Address - Phone:478-952-6703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007434101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional