Healthcare Provider Details

I. General information

NPI: 1669057287
Provider Name (Legal Business Name): SALLY ANN SMITH LMSW, BCBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SALLY ANN FREDERICK

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 06/05/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5242 PLAINFIELD AVE NE STE A
GRAND RAPIDS MI
49525-1084
US

IV. Provider business mailing address

19 RADNY DR
LOWELL MI
49331-9131
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-2200
  • Fax:
Mailing address:
  • Phone: 616-901-7180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801084828
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: