Provider Demographics
NPI:1750779237
Name:SMITH, LANA (CSW006563)
Entity type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CSW006563
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1105 GREGG HWY
Mailing Address - Street 2:
Mailing Address - City:AIKEN
Mailing Address - State:SC
Mailing Address - Zip Code:29801-6341
Mailing Address - Country:US
Mailing Address - Phone:803-649-1900
Mailing Address - Fax:803-643-2926
Practice Address - Street 1:1145 PINE LAKE DR
Practice Address - Street 2:
Practice Address - City:GRAYSON
Practice Address - State:GA
Practice Address - Zip Code:30017-7926
Practice Address - Country:US
Practice Address - Phone:404-522-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-06
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
SCSC-10430101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC570569761OtherTAX ID
SCAD01AKMedicaid