Provider Demographics
NPI:1659998623
Name:SMITH, CHANELL N
Entity type:Individual
Prefix:
First Name:CHANELL
Middle Name:N
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 1:1104 N LILAC LN
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-8171
Mailing Address - Country:US
Mailing Address - Phone:708-527-0936
Mailing Address - Fax:
Practice Address - Street 1:1104 N LILAC LN
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-8171
Practice Address - Country:US
Practice Address - Phone:708-527-0936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-25
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
NC009650373I171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician