Provider Demographics
NPI:1710341656
Name:SMITH, CATHY
Entity type:Individual
Prefix:
First Name:CATHY
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 1:1005 MAPLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-7113
Mailing Address - Country:US
Mailing Address - Phone:770-891-3165
Mailing Address - Fax:
Practice Address - Street 1:1005 MAPLE CREEK DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-7113
Practice Address - Country:US
Practice Address - Phone:770-891-3165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-06
Last Update Date:2025-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPC011089101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty