Provider Demographics
NPI:1770998858
Name:SMITH, LATASHA MACHELLE-KELLY (LCSW-A)
Entity type:Individual
Prefix:MRS
First Name:LATASHA
Middle Name:MACHELLE-KELLY
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 ASHBURY SQ
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-8741
Mailing Address - Country:US
Mailing Address - Phone:910-778-3049
Mailing Address - Fax:
Practice Address - Street 1:210 ASHBURY SQ
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-8741
Practice Address - Country:US
Practice Address - Phone:910-778-3049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-26
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP007600251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health