Provider Demographics
NPI:1225815053
Name:SMITH, DEBRA LYNN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8135 COXS DR STE 110
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-5898
Mailing Address - Country:US
Mailing Address - Phone:269-501-7716
Mailing Address - Fax:
Practice Address - Street 1:8135 COXS DR STE 110
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-5898
Practice Address - Country:US
Practice Address - Phone:269-501-7716
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician