Healthcare Provider Details

I. General information

NPI: 1518589126
Provider Name (Legal Business Name): SHANDRA SMITH M.A., LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17224 VAN WAGONER RD
SPRING LAKE MI
49456-9702
US

IV. Provider business mailing address

2655 SIMONELLI RD
MUSKEGON MI
49445-8678
US

V. Phone/Fax

Practice location:
  • Phone: 616-296-2130
  • Fax: 616-296-2148
Mailing address:
  • Phone: 231-766-2969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401019618
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: