Basic Information
| Provider Information | |||||||||
| NPI: | 1992946529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | ILEAH-MARE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | LPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICHOLS | ||||||||
| OtherFirstName: | ILEAH-MARE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6549 TOWN CENTER DR STE A | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486206400 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8150 E 13 MILE RD | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480938700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5868259700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2009 | ||||||||
| LastUpdateDate: | 01/18/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401009805 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.