Provider Demographics
NPI:1275818551
Name:SMITH, NANCY JO (MA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JO
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 HEATHER CT
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-6817
Mailing Address - Country:US
Mailing Address - Phone:616-403-9549
Mailing Address - Fax:
Practice Address - Street 1:44 E 8TH ST
Practice Address - Street 2:SUITE 230
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423-3575
Practice Address - Country:US
Practice Address - Phone:616-613-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011450101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional