Provider Demographics
NPI:1659079119
Name:SMITH, TENNILLE B (LPC)
Entity Type:Individual
Prefix:
First Name:TENNILLE
Middle Name:B
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:TENNILLE
Other - Middle Name:B
Other - Last Name:LOTT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN
Mailing Address - Street 1:4970 WEWATTA ST SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-7521
Mailing Address - Country:US
Mailing Address - Phone:678-777-2505
Mailing Address - Fax:
Practice Address - Street 1:4970 WEWATTA ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-7521
Practice Address - Country:US
Practice Address - Phone:678-777-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-22
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC013226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health