=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922490465
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALYSSA JEAN SMITH LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2015
-----------------------------------------------------
Last Update Date | 10/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2730 5 MILE RD NE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49525-6518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-426-9159
-----------------------------------------------------
Fax | 616-222-0294
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7 ANN ST NW
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49505-6247
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-914-6510
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801100338
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------