Basic Information
| Provider Information | |||||||||
| NPI: | 1124140017 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | BYRNE | ||||||||
| MiddleName: | CRAIG | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2257 | ||||||||
| Address2: | |||||||||
| City: | CHESTERTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463040357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2199268320 | ||||||||
| FaxNumber: | 2199263524 | ||||||||
| Practice Location | |||||||||
| Address1: | 1905 ABBOT RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488238571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172828249 | ||||||||
| FaxNumber: | 5172537119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2007 | ||||||||
| LastUpdateDate: | 11/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301014029 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.