Healthcare Provider Details

I. General information

NPI: 1578514584
Provider Name (Legal Business Name): LEWIS SMITH PH.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1655 W BIG BEAVER RD
TROY MI
48084-3501
US

IV. Provider business mailing address

1655 W BIG BEAVER RD
TROY MI
48084-3501
US

V. Phone/Fax

Practice location:
  • Phone: 248-644-2955
  • Fax: 248-644-0237
Mailing address:
  • Phone: 248-644-2955
  • Fax: 248-644-0237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number6201002143
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301002143
License Number StateMI

VIII. Authorized Official

Name: DR. LEWIS WILSON SMITH
Title or Position: LICENSED PSYCHOLOGIST
Credential: PH.D.
Phone: 248-644-2955