Provider Demographics
NPI:1518442250
Name:SMITH, GRIFFIN BLAKE (LCSW)
Entity Type:Individual
Prefix:
First Name:GRIFFIN
Middle Name:BLAKE
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 MARHAM PARK CIR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-5449
Mailing Address - Country:US
Mailing Address - Phone:678-468-0965
Mailing Address - Fax:
Practice Address - Street 1:3815 MARHAM PARK CIR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-5449
Practice Address - Country:US
Practice Address - Phone:470-412-1311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-28
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW007450104100000X
GACSW0068411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker