Provider Demographics
NPI:1386719771
Name:SMITH, SHELLY JEAN (LMSW)
Entity type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 S. BANNER RD
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471
Mailing Address - Country:US
Mailing Address - Phone:810-648-4095
Mailing Address - Fax:
Practice Address - Street 1:190 DELAWARE ST.
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471
Practice Address - Country:US
Practice Address - Phone:810-583-0333
Practice Address - Fax:810-648-5107
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010875911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical