Provider Demographics
NPI:1720683204
Name:SMITH, DERRICKA E (MA LLP)
Entity type:Individual
Prefix:
First Name:DERRICKA
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13725 STARR COMMONWEALTH RD
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:MI
Mailing Address - Zip Code:49224-9525
Mailing Address - Country:US
Mailing Address - Phone:800-837-5591
Mailing Address - Fax:
Practice Address - Street 1:329 N MULBERRY ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MI
Practice Address - Zip Code:49068-1017
Practice Address - Country:US
Practice Address - Phone:269-358-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-02
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007895103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist