Healthcare Provider Details

I. General information

NPI: 1235426545
Provider Name (Legal Business Name): EDITH RENA SMITH CERTIFIED PEER SUPPO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E MCNICHOLS RD
DETROIT MI
48203-2857
US

IV. Provider business mailing address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-3100
  • Fax: 313-365-3101
Mailing address:
  • Phone: 313-347-2068
  • Fax: 313-825-2429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number2008
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: