Healthcare Provider Details

I. General information

NPI: 1255219465
Provider Name (Legal Business Name): HEATHER RENEE SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2025
Last Update Date: 08/25/2025
Certification Date: 08/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20332 EUREKA RD
TAYLOR MI
48180-5310
US

IV. Provider business mailing address

2733 E 12TH ST PH A2ND
BROOKLYN NY
11235-4669
US

V. Phone/Fax

Practice location:
  • Phone: 833-455-8622
  • Fax:
Mailing address:
  • Phone: 833-455-8622
  • 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: