Provider Demographics
NPI:1669944260
Name:SMITH, JAMES ANTONIO (BSC, CADC II, ICADC)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ANTONIO
Last Name:SMITH
Suffix:
Gender:M
Credentials:BSC, CADC II, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 CASTLEBOTTOM DR
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30045-2796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:669 CASTLEBOTTOM DR
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-2796
Practice Address - Country:US
Practice Address - Phone:518-955-8868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1140101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1140OtherTHE ALCOHOL AND DRUG ABUSE CERTIFICATION BOARD OF GEORGIA, INC.
PA806645OtherINTERNATIONAL CERTIFICATION & RECIPROCITY CONSORTIUM