Healthcare Provider Details

I. General information

NPI: 1174051007
Provider Name (Legal Business Name): SAMANTHA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24445 NORTHWESTERN HWY
SOUTHFIELD MI
48075
US

IV. Provider business mailing address

1037 HIGH RIDGE DRIVE
CANTON MI
48187
US

V. Phone/Fax

Practice location:
  • Phone: 248-483-7804
  • Fax:
Mailing address:
  • Phone: 313-587-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401011910
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6451011910
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451011910
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: