Provider Demographics
NPI:1992377378
Name:SMITH, DONTERIO MARQUELL (LPC)
Entity Type:Individual
Prefix:
First Name:DONTERIO
Middle Name:MARQUELL
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:277 MARTIN LUTHER KING JR BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-3498
Mailing Address - Country:US
Mailing Address - Phone:478-745-2811
Mailing Address - Fax:478-745-0881
Practice Address - Street 1:277 MARTIN LUTHER KING JR BLVD STE 203
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-3498
Practice Address - Country:US
Practice Address - Phone:478-745-2811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC012306101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional