Provider Demographics
NPI:1023610482
Name:SMITH, RANDOLPH QUIN (PROFESSIONAL COUNSEL)
Entity type:Individual
Prefix:
First Name:RANDOLPH
Middle Name:QUIN
Last Name:SMITH
Suffix:
Gender:M
Credentials:PROFESSIONAL COUNSEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3448 PACES FERRY CIR SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30080-3127
Mailing Address - Country:US
Mailing Address - Phone:404-414-1387
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD SE STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:678-568-9288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC007602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional