Provider Demographics
NPI:1265300164
Name:SMITH, CALLIE GRACE
Entity type:Individual
Prefix:
First Name:CALLIE
Middle Name:GRACE
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 1:4304 GRAND POINTE WAY # 4304
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525-3520
Mailing Address - Country:US
Mailing Address - Phone:855-444-5664
Mailing Address - Fax:855-444-5664
Practice Address - Street 1:102 MARSH HARBOUR PKWY STE 104
Practice Address - Street 2:
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6755
Practice Address - Country:US
Practice Address - Phone:855-444-5664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-23
Last Update Date:2025-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA060292967106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty