Provider Demographics
NPI:1215447743
Name:SMITH, MICHELLE R
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:R
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 1:5344 CHATEAU THIERRY BLVD
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48383-2610
Mailing Address - Country:US
Mailing Address - Phone:248-979-3888
Mailing Address - Fax:
Practice Address - Street 1:5344 CHATEAU THIERRY BLVD
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48383-2610
Practice Address - Country:US
Practice Address - Phone:248-979-3888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist