Provider Demographics
NPI:1235426545
Name:SMITH, EDITH RENA (CERTIFIED PEER SUPPO)
Entity Type:Individual
Prefix:MS
First Name:EDITH
Middle Name:RENA
Last Name:SMITH
Suffix:
Gender:F
Credentials:CERTIFIED PEER SUPPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 W MILWAUKEE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2943
Mailing Address - Country:US
Mailing Address - Phone:313-347-2068
Mailing Address - Fax:313-825-2429
Practice Address - Street 1:1121 E MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2857
Practice Address - Country:US
Practice Address - Phone:313-365-3100
Practice Address - Fax:313-365-3101
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-07
Last Update Date:2023-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2008175T00000X
MI101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2018OtherCERIFIED PEER RECOVERY COACH
MI2008OtherCERIFIED PEER SUPPORT SPECIALIST