Provider Demographics
NPI:1700304904
Name:SMITH, MICHAEL SCOTT (PSY)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:PSY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 RIDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30240-2236
Mailing Address - Country:US
Mailing Address - Phone:706-884-5050
Mailing Address - Fax:
Practice Address - Street 1:610 RIDLEY AVE
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2236
Practice Address - Country:US
Practice Address - Phone:706-884-5050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-07
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC009754101YP2500X
GAPSY004636103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional