MEDICARE: DERRIELLE SMITH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801016587	MI

General Provider Information

NPI Number	:	1023304466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DERRIELLE SMITH

Provider Business Mailing Address
First Line	:	42307 OLD BRIDGE RD
Second Line	:
City	:	CANTON
State	:	MI
Zip	:	48188-1138
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	37899 W 12 MILE RD
Second Line	:	SUITE 130
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48331-3048
Country	:	US
Telephone Number	:	248-476-2229
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2011
Last Update Date	:	06/23/2011

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Directions to “ DERRIELLE SMITH ” Practice Location

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