Healthcare Provider Details

I. General information

NPI: 1750869384
Provider Name (Legal Business Name): MICHAEL SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4636 E 175TH ST
CLEVELAND OH
44128-3930
US

IV. Provider business mailing address

4636 E 175TH ST
CLEVELAND OH
44128-3930
US

V. Phone/Fax

Practice location:
  • Phone: 216-254-4862
  • Fax:
Mailing address:
  • Phone: 216-254-4862
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberLCDCII.091046
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: