Provider Demographics
NPI:1023042983
Name:SMITH, STEPHEN JAMES
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:JAMES
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 ELDON BAKER DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-1923
Mailing Address - Country:US
Mailing Address - Phone:810-744-3600
Mailing Address - Fax:
Practice Address - Street 1:23400 MICHIGAN AVE
Practice Address - Street 2:SUITE 405
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1924
Practice Address - Country:US
Practice Address - Phone:810-744-3600
Practice Address - Fax:810-744-2597
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010669751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0M97450005Medicare ID - Type Unspecified