Provider Demographics
NPI:1083965537
Name:SMITH, COURTNEY (LLMSW)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17100 W 12 MILE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-2115
Mailing Address - Country:US
Mailing Address - Phone:248-443-1995
Mailing Address - Fax:
Practice Address - Street 1:17100 W 12 MILE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-2115
Practice Address - Country:US
Practice Address - Phone:248-443-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801094821104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6801094821OtherLIMITED LICENSE SOCIAL WORK PERMANENT ID