Provider Demographics
NPI:1790105021
Name:SMITH, NICOLE RENE (LPC)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:RENE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 863
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30722-0863
Mailing Address - Country:US
Mailing Address - Phone:706-279-0405
Mailing Address - Fax:706-279-4190
Practice Address - Street 1:1414 DUG GAP RD
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-5007
Practice Address - Country:US
Practice Address - Phone:706-279-0405
Practice Address - Fax:706-279-4190
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007053101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional