Provider Demographics
NPI:1184288821
Name:SMITH, AUDREY CAMILLE (LPCA)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:CAMILLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 BALSAM TREE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269-0692
Mailing Address - Country:US
Mailing Address - Phone:828-514-5612
Mailing Address - Fax:
Practice Address - Street 1:2324 CONCORD LAKE RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2814
Practice Address - Country:US
Practice Address - Phone:704-918-1343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA12916101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional