Healthcare Provider Details

I. General information

NPI: 1376533265
Provider Name (Legal Business Name): PAUL LUCKI SMITH PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2005
Last Update Date: 10/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15655 33 MILE RD
ARMADA MI
48005-3400
US

IV. Provider business mailing address

15655 33 MILE RD
ARMADA MI
48005-3400
US

V. Phone/Fax

Practice location:
  • Phone: 586-747-0206
  • Fax:
Mailing address:
  • Phone: 586-747-0206
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301012845
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: