Provider Demographics
NPI:1952133118
Name:SMITH, MARILYN
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:
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 1:100 RANDOMWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-5070
Mailing Address - Country:US
Mailing Address - Phone:770-712-3689
Mailing Address - Fax:
Practice Address - Street 1:515 E CROSSVILLE RD STE 140
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-5861
Practice Address - Country:US
Practice Address - Phone:770-712-3689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC009534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health