1093054603 NPI number — MRS. KRISTINE COLLURO SMITH LCSW

Table of content: MRS. KRISTINE COLLURO SMITH LCSW (NPI 1093054603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093054603 NPI number — MRS. KRISTINE COLLURO SMITH LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
KRISTINE
Provider Middle Name:
COLLURO
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093054603
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
881 PONCE DE LEON AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30306-4252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-226-7536
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
791 VIRGINIA AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30306-3630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-226-7536
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/04/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  CSW003413 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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