Provider Demographics
NPI:1700028446
Name:SMITH, JUDITH TESSA (LAPC)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:TESSA
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3441 CYPRESS MILL RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-2878
Mailing Address - Country:US
Mailing Address - Phone:912-554-8542
Mailing Address - Fax:912-264-5965
Practice Address - Street 1:3045 SCARLETT ST
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1251
Practice Address - Country:US
Practice Address - Phone:912-554-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-26
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001868101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health