Provider Demographics
NPI:1871993840
Name:SMITH, ALTHEA (MENTAL HEALTH)
Entity type:Individual
Prefix:
First Name:ALTHEA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MENTAL HEALTH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26677 W 12 MILE RD STE 136
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1514
Mailing Address - Country:US
Mailing Address - Phone:248-990-6384
Mailing Address - Fax:313-924-5694
Practice Address - Street 1:26677 W 12 MILE RD STE 136
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1514
Practice Address - Country:US
Practice Address - Phone:248-990-6384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-27
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401014365101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor