Provider Demographics
NPI:1407392731
Name:SMITH, MATTHEW (MA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6692 SPRING ARBOR RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-9322
Mailing Address - Country:US
Mailing Address - Phone:517-750-3869
Mailing Address - Fax:517-750-3673
Practice Address - Street 1:6692 SPRING ARBOR RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-9322
Practice Address - Country:US
Practice Address - Phone:517-750-3869
Practice Address - Fax:517-750-3673
Is Sole Proprietor?:No
Enumeration Date:2017-01-10
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016989103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist