Healthcare Provider Details

I. General information

NPI: 1770062572
Provider Name (Legal Business Name): LETISHA ERICA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2018
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 N WASHINGTON SQ STE 307
LANSING MI
48933-1617
US

IV. Provider business mailing address

219 LAHOMA ST
LANSING MI
48915-1821
US

V. Phone/Fax

Practice location:
  • Phone: 517-391-6276
  • Fax: 517-580-7522
Mailing address:
  • Phone: 517-391-6276
  • Fax: 517-580-7522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TH0100X
TaxonomyHealth Service Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: