Provider Demographics
NPI:1811013485
Name:SMITH, CONNIE BURCHETTE (PHD)
Entity Type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:BURCHETTE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CONNIE
Other - Middle Name:BURCHETTE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:3675 CRESTWOOD PKWY NW
Mailing Address - Street 2:SUITE 550
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-1805
Mailing Address - Country:US
Mailing Address - Phone:770-491-1162
Mailing Address - Fax:770-491-1162
Practice Address - Street 1:3675 CRESTWOOD PKWY NW
Practice Address - Street 2:SUITE 550
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-1805
Practice Address - Country:US
Practice Address - Phone:770-491-1162
Practice Address - Fax:770-491-1162
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1732103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist