Healthcare Provider Details

I. General information

NPI: 1922490465
Provider Name (Legal Business Name): ALYSSA JEAN SMITH LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2015
Last Update Date: 10/11/2020
Certification Date: 10/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 5 MILE RD NE
GRAND RAPIDS MI
49525-6518
US

IV. Provider business mailing address

7 ANN ST NW
GRAND RAPIDS MI
49505-6247
US

V. Phone/Fax

Practice location:
  • Phone: 616-426-9159
  • Fax: 616-222-0294
Mailing address:
  • Phone: 616-914-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801100338
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: