Healthcare Provider Details

I. General information

NPI: 1164735452
Provider Name (Legal Business Name): MICHELLE CHRISTINA SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 W MAIN ST STE 102A
MONROE WA
98272-2030
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 360-805-3122
  • Fax: 360-805-9180
Mailing address:
  • Phone: 206-764-3335
  • Fax: 206-764-0489

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMC60176868
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: