Provider Demographics
NPI:1376533265
Name:SMITH, PAUL LUCKI (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:LUCKI
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15655 33 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ARMADA
Mailing Address - State:MI
Mailing Address - Zip Code:48005-3400
Mailing Address - Country:US
Mailing Address - Phone:586-747-0206
Mailing Address - Fax:
Practice Address - Street 1:15655 33 MILE RD
Practice Address - Street 2:
Practice Address - City:ARMADA
Practice Address - State:MI
Practice Address - Zip Code:48005-3400
Practice Address - Country:US
Practice Address - Phone:586-747-0206
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2013-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012845103TC0700X
103G00000X, 103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)