Provider Demographics
NPI:1437758620
Name:SMITH, CHARLES VINCENT (MS, APC, NCC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:VINCENT
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS, APC, NCC
Other - Prefix:MR
Other - First Name:CHARLES
Other - Middle Name:V
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, APC, NCC
Mailing Address - Street 1:9805 AUTRY FALLS DR
Mailing Address - Street 2:
Mailing Address - City:JOHNS CREEK
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8095
Mailing Address - Country:US
Mailing Address - Phone:917-603-9287
Mailing Address - Fax:
Practice Address - Street 1:740 CAMERON M ALEXANDER BLVD NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30318-6812
Practice Address - Country:US
Practice Address - Phone:917-603-9287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-20
Last Update Date:2020-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC007540101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health