Provider Demographics
NPI:1104675248
Name:SMITH, WILLIE DEVON
Entity type:Individual
Prefix:
First Name:WILLIE
Middle Name:DEVON
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2701 E LAFAYETTE ST APT 5
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-3954
Mailing Address - Country:US
Mailing Address - Phone:713-291-1249
Mailing Address - Fax:
Practice Address - Street 1:2701 E LAFAYETTE ST APT 5
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3954
Practice Address - Country:US
Practice Address - Phone:713-291-1249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-13
Last Update Date:2024-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Single Specialty