Provider Demographics
NPI:1932820073
Name:SMITH, BONNIE M
Entity Type:Individual
Prefix:
First Name:BONNIE
Middle Name:M
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 1:800 KENNESAW AVE NW STE 250
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-7944
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 KENNESAW AVE NW STE 250
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-7944
Practice Address - Country:US
Practice Address - Phone:770-485-3224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103T00000X
NE13131101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103T00000XBehavioral Health & Social Service ProvidersPsychologist