Healthcare Provider Details

I. General information

NPI: 1407563026
Provider Name (Legal Business Name): KATHERINE MARY SMITH MS, TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

37625 PEMBROKE AVE
LIVONIA MI
48152-1050
US

IV. Provider business mailing address

37625 PEMBROKE AVE
LIVONIA MI
48152-1050
US

V. Phone/Fax

Practice location:
  • Phone: 313-656-4052
  • Fax:
Mailing address:
  • Phone: 313-656-4052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362009656
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: