Healthcare Provider Details

I. General information

NPI: 1982953675
Provider Name (Legal Business Name): MICHAELA D.M. SMITH PSYD, LP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2012
Last Update Date: 02/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 WOODWINDS DR
WOODBURY MN
55125-2270
US

IV. Provider business mailing address

1700 UNIVERSITY AVE W 6TH FLOOR
SAINT PAUL MN
55104-3727
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-0100
  • Fax:
Mailing address:
  • Phone: 651-232-2273
  • Fax: 651-232-4953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLP5813
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: