Provider Demographics
NPI:1083189922
Name:SMITH, ISAAC
Entity Type:Individual
Prefix:
First Name:ISAAC
Middle Name:
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:PO BOX 491
Mailing Address - Street 2:
Mailing Address - City:HOWARD CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49329-0491
Mailing Address - Country:US
Mailing Address - Phone:267-300-4857
Mailing Address - Fax:
Practice Address - Street 1:625 KENMOOR AVE SUITE 301
Practice Address - Street 2:PMB 95061
Practice Address - City:GRAND RAPIDS MI
Practice Address - State:MI
Practice Address - Zip Code:49546
Practice Address - Country:US
Practice Address - Phone:267-300-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106S00000X
MI7401001192103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician