Provider Demographics
NPI:1710749932
Name:SMITH, SHAKHIRYA SATOMI
Entity Type:Individual
Prefix:
First Name:SHAKHIRYA
Middle Name:SATOMI
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 1:324 BELMONT DR
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5975
Mailing Address - Country:US
Mailing Address - Phone:191-768-4837
Mailing Address - Fax:
Practice Address - Street 1:1225 NORTHBROOK PKWY
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-2933
Practice Address - Country:US
Practice Address - Phone:678-542-2330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARBT-23-291216106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty