Provider Demographics
NPI:1407612807
Name:SMITH, GRAYSON
Entity Type:Individual
Prefix:
First Name:GRAYSON
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 BALDWIN HEIGHTS RD
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:GA
Mailing Address - Zip Code:30511-2962
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:82 COLLEGE CIR
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30597-2962
Practice Address - Country:US
Practice Address - Phone:706-864-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-23
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer