Healthcare Provider Details

I. General information

NPI: 1730144239
Provider Name (Legal Business Name): DIANE S SMITH PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 KERCHEVAL AVE
GROSSE POINTE FARMS MI
48236-3696
US

IV. Provider business mailing address

1506 LOCHMOOR BLVD
GROSSE POINTE WOODS MI
48236-4016
US

V. Phone/Fax

Practice location:
  • Phone: 313-881-2010
  • Fax: 313-882-7424
Mailing address:
  • Phone: 313-881-2010
  • Fax: 313-882-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number110675
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number110675
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6301007629
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801017113
License Number StateMI

VIII. Authorized Official

Name: DIANE SHARON SMITH
Title or Position: PRESIDENT
Credential: PHD APRN NP CNS
Phone: 313-882-7424