Provider Demographics
NPI:1710377080
Name:SMITH, LAQUILLA SHAUNTE' (MSSA, LSW)
Entity Type:Individual
Prefix:
First Name:LAQUILLA
Middle Name:SHAUNTE'
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSSA, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2866 MAYFIELD RD
Mailing Address - Street 2:APT 304
Mailing Address - City:CLEVELAND HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-5200
Mailing Address - Country:US
Mailing Address - Phone:864-238-2361
Mailing Address - Fax:
Practice Address - Street 1:10427 DETROIT AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44102-1645
Practice Address - Country:US
Practice Address - Phone:216-521-6511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.1451377104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker