Healthcare Provider Details

I. General information

NPI: 1033667514
Provider Name (Legal Business Name): PETRA SMITH LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 W SAINT JOSEPH ST STE A101
LANSING MI
48917-3665
US

IV. Provider business mailing address

2220 MARGUERITE AVE
LANSING MI
48912-3246
US

V. Phone/Fax

Practice location:
  • Phone: 517-321-5900
  • Fax: 517-321-5945
Mailing address:
  • Phone: 517-449-8174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801082849
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: