Healthcare Provider Details

I. General information

NPI: 1841840568
Provider Name (Legal Business Name): LACEY SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2019
Last Update Date: 10/24/2025
Certification Date: 10/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

252 EDISON PARK AVE NW
GRAND RAPIDS MI
49504-5906
US

IV. Provider business mailing address

252 EDISON PARK AVE NW
GRAND RAPIDS MI
49504-5906
US

V. Phone/Fax

Practice location:
  • Phone: 989-331-0529
  • Fax:
Mailing address:
  • Phone: 989-331-0529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149021492
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: