MEDICARE: ALEXIS SMITH

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	106S00000X	Behavior Technician
2	101YM0800X	Mental Health Counselor	6451022613	MI

General Provider Information

NPI Number	:	1588145866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALEXIS SMITH

Provider Business Mailing Address
First Line	:	6255 28TH ST SE
Second Line	:	SUITE 3 OFFICE D
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-1565
Country	:	US
Telephone Number	:	616-284-1527
Fax Number	:

Provider Business Practice Location Address
First Line	:	6255 28TH ST SE
Second Line	:	SUITE 3 OFFICE D
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-1565
Country	:	US
Telephone Number	:	616-284-1527
Fax Number	:

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

Provider Enumeration Date	:	08/24/2018
Last Update Date	:	01/02/2024

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