Healthcare Provider Details

I. General information

NPI: 1356075840
Provider Name (Legal Business Name): MICHELLE CLARICE SMITH M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 07/12/2022
Certification Date: 07/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 S BROAD ST
CLINTON SC
29325-2507
US

IV. Provider business mailing address

302 S BROAD ST
CLINTON SC
29325-2507
US

V. Phone/Fax

Practice location:
  • Phone: 864-938-2100
  • Fax:
Mailing address:
  • Phone: 864-938-2100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberIMH13743
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: