Provider Demographics
NPI:1922579549
Name:SMITH, STEPHEN DUSTIN (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:DUSTIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5180 FIELDGATE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30028-5918
Mailing Address - Country:US
Mailing Address - Phone:678-933-2517
Mailing Address - Fax:770-406-8872
Practice Address - Street 1:104 PILGRIM VILLAGE DR STE 300
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-9232
Practice Address - Country:US
Practice Address - Phone:678-933-2517
Practice Address - Fax:770-406-8872
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-07
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0065841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical