Healthcare Provider Details

I. General information

NPI: 1477056257
Provider Name (Legal Business Name): ANGELA JILL SMITH LLPC, LLMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2018
Last Update Date: 07/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 36TH ST SE
GRAND RAPIDS MI
49512-2810
US

IV. Provider business mailing address

PO BOX 114
CASNOVIA MI
49318-0114
US

V. Phone/Fax

Practice location:
  • Phone: 616-942-7294
  • Fax:
Mailing address:
  • Phone: 616-745-9743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401016543
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101006790
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: