Provider Demographics
NPI:1659911063
Name:ODETTA SMILEY, PSYD, LPC, LLC.
Entity Type:Organization
Organization Name:ODETTA SMILEY, PSYD, LPC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ODETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:SMILEY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:478-227-2419
Mailing Address - Street 1:20 JOSHUA CIR
Mailing Address - Street 2:
Mailing Address - City:ELLABELL
Mailing Address - State:GA
Mailing Address - Zip Code:31308-7301
Mailing Address - Country:US
Mailing Address - Phone:912-655-1811
Mailing Address - Fax:
Practice Address - Street 1:185 RICHARD DAVIS DR STE 102
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324-3978
Practice Address - Country:US
Practice Address - Phone:912-304-3051
Practice Address - Fax:844-904-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-01-14
Last Update Date:2023-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003140039AMedicaid
1194082818OtherNPI 1