Healthcare Provider Details

I. General information

NPI: 1780935536
Provider Name (Legal Business Name): KIM MARIE SMITH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2012
Last Update Date: 10/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31800 NORTHWESTERN HWY SUITE 201
FARMINGTON HILLS MI
48334-1655
US

IV. Provider business mailing address

20590 WAYLAND ST
SOUTHFIELD MI
48076-3157
US

V. Phone/Fax

Practice location:
  • Phone: 248-557-3820
  • Fax:
Mailing address:
  • Phone: 248-557-3820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301015598
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: