MEDICARE: KERIELLE SMITH O.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	5201009270	MI

General Provider Information

NPI Number	:	1548711146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KERIELLE SMITH O.T.

Provider Business Mailing Address
First Line	:	24410 MIDDLEBELT RD
Second Line	:
City	:	NEW BOSTON
State	:	MI
Zip	:	48164-9487
Country	:	US
Telephone Number	:	734-664-8180
Fax Number	:	888-304-2739

Provider Business Practice Location Address
First Line	:	24410 MIDDLEBELT RD
Second Line	:
City	:	NEW BOSTON
State	:	MI
Zip	:	48164-9487
Country	:	US
Telephone Number	:	734-664-8180
Fax Number	:	888-304-2739

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2016
Last Update Date	:	10/18/2016

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