Healthcare Provider Details

I. General information

NPI: 1083189922
Provider Name (Legal Business Name): ISAAC SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 03/09/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 KENMOOR AVE SUITE 301 PMB 95061
GRAND RAPIDS MI MI
49546
US

IV. Provider business mailing address

PO BOX 491
HOWARD CITY MI
49329-0491
US

V. Phone/Fax

Practice location:
  • Phone: 267-300-4857
  • Fax:
Mailing address:
  • Phone: 267-300-4857
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401001192
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: