Basic Information
| Provider Information | |||||||||
| NPI: | 1982953675 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | MICHAELA | ||||||||
| MiddleName: | D.M. | ||||||||
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| Credential: | PSYD, LP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 UNIVERSITY AVE W | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551043727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512322273 | ||||||||
| FaxNumber: | 6512324953 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 WOODWINDS DR | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512320100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2012 | ||||||||
| LastUpdateDate: | 02/05/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | LP5813 | MN | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.