Healthcare Provider Details

I. General information

NPI: 1629243902
Provider Name (Legal Business Name): GLENDA FAYE SMITH MT REFLEXOLOGIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2008
Last Update Date: 04/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15041 FAUST
DETROIT MI
48223
US

IV. Provider business mailing address

15041 FAUST
DETROIT MI
48223-2324
US

V. Phone/Fax

Practice location:
  • Phone: 313-272-3702
  • Fax:
Mailing address:
  • Phone: 313-272-3702
  • Fax: 313-272-3702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: