Healthcare Provider Details

I. General information

NPI: 1770232712
Provider Name (Legal Business Name): BENJAMIN SMITH JR. LLBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2022
Last Update Date: 03/18/2022
Certification Date: 03/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9641 HARPER AVE
DETROIT MI
48213-2731
US

IV. Provider business mailing address

48481 BEACON SQUARE DR
MACOMB MI
48044-1445
US

V. Phone/Fax

Practice location:
  • Phone: 313-481-1210
  • Fax:
Mailing address:
  • Phone: 313-737-9016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6852093136
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: