Healthcare Provider Details

I. General information

NPI: 1205637378
Provider Name (Legal Business Name): MIKEYLA KALISE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2025
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29566 NORTHWESTERN HWY
SOUTHFIELD MI
48034-1032
US

IV. Provider business mailing address

1492 E BELTLINE AVE SE
GRAND RAPIDS MI
49506-4336
US

V. Phone/Fax

Practice location:
  • Phone: 833-328-8476
  • Fax: 248-779-1819
Mailing address:
  • Phone: 616-666-4816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: