Provider Demographics
NPI:1851817480
Name:SMITH, MYKEIA J
Entity Type:Individual
Prefix:
First Name:MYKEIA
Middle Name:J
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:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:SOUTHMONT
Mailing Address - State:NC
Mailing Address - Zip Code:27351-0180
Mailing Address - Country:US
Mailing Address - Phone:919-627-5450
Mailing Address - Fax:
Practice Address - Street 1:5809 DEPARTURE DR STE 106
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-1936
Practice Address - Country:US
Practice Address - Phone:919-872-6220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-15
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NCP0117971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health