Provider Demographics
NPI:1205369618
Name:SMITH-TATE, KELLIE (LLMSW)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:SMITH-TATE
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 1:130 HAMPTON CIR
Mailing Address - Street 2:100
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-4195
Mailing Address - Country:US
Mailing Address - Phone:248-853-0750
Mailing Address - Fax:
Practice Address - Street 1:130 HAMPTON CIR
Practice Address - Street 2:100
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-4195
Practice Address - Country:US
Practice Address - Phone:248-853-0750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011005621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical