Provider Demographics
NPI:1407216468
Name:SMITH, RUTH (MA, LBSW)
Entity Type:Individual
Prefix:MRS
First Name:RUTH
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 E FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-1024
Mailing Address - Country:US
Mailing Address - Phone:313-213-0797
Mailing Address - Fax:
Practice Address - Street 1:1025 E FOREST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1024
Practice Address - Country:US
Practice Address - Phone:313-213-0797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-03
Last Update Date:2016-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802034593103K00000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802034593Medicaid