Provider Demographics
NPI:1639637333
Name:SMITH, SHANIKA LAVONDA
Entity Type:Individual
Prefix:
First Name:SHANIKA
Middle Name:LAVONDA
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 1:18444 BLACK CREEK RD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:VA
Mailing Address - Zip Code:23851-3627
Mailing Address - Country:US
Mailing Address - Phone:757-742-2362
Mailing Address - Fax:
Practice Address - Street 1:18444 BLACK CREEK RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:VA
Practice Address - Zip Code:23851-3627
Practice Address - Country:US
Practice Address - Phone:757-742-2362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0711000491101YA0400X
VA251C00000X
VA0710103685101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA07161997Medicaid