Healthcare Provider Details

I. General information

NPI: 1760936942
Provider Name (Legal Business Name): RENEE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2016
Last Update Date: 01/13/2025
Certification Date: 01/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18603 BLACKMOOR ST
DETROIT MI
48234-3719
US

IV. Provider business mailing address

18603 BLACKMOOR ST
DETROIT MI
48234-3719
US

V. Phone/Fax

Practice location:
  • Phone: 313-526-3269
  • Fax:
Mailing address:
  • Phone: 313-542-2497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number149028399
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: