Basic Information
| Provider Information | |||||||||
| NPI: | 1184029340 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA LPC CRC SCL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2775 COLRAIN DR | ||||||||
| Address2: | |||||||||
| City: | WATERFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483283618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487386646 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9315 TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482391260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134504500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2014 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 00014088 | MI | N | Behavioral Health & Social Service Providers | Counselor | 101YS0200X | MI-SC0000000749838 | MI | N | Behavioral Health & Social Service Providers | Counselor | School | 101YP2500X | 6401005523 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.