Provider Demographics
NPI:1730937319
Name:SMITH, CHARMAINE (LMBT, LMT)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMBT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2183 RIVER PARK CT
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30907-2039
Mailing Address - Country:US
Mailing Address - Phone:919-703-9903
Mailing Address - Fax:
Practice Address - Street 1:2183 RIVER PARK CT
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-2039
Practice Address - Country:US
Practice Address - Phone:919-703-9903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA011611225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist