Healthcare Provider Details

I. General information

NPI: 1992946529
Provider Name (Legal Business Name): ILEAH-MARE SMITH-ALLEN LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ILEAH-MARE NICHOLS

II. Dates (important events)

Enumeration Date: 03/11/2009
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8150 E 13 MILE RD
WARREN MI
48093-8700
US

IV. Provider business mailing address

29623 NORTHWESTERN HWY STE 6
SOUTHFIELD MI
48034-1076
US

V. Phone/Fax

Practice location:
  • Phone: 586-825-9700
  • Fax:
Mailing address:
  • Phone: 313-932-5527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401009805
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: