Healthcare Provider Details

I. General information

NPI: 1255247417
Provider Name (Legal Business Name): RYAN NOELLE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15173 NORTH RD STE 100
FENTON MI
48430-1381
US

IV. Provider business mailing address

23660 PADDOCK DR
FARMINGTON HILLS MI
48336-2226
US

V. Phone/Fax

Practice location:
  • Phone: 810-771-4074
  • Fax:
Mailing address:
  • Phone: 810-771-4074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362010393
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: