Provider Demographics
NPI:1477056257
Name:SMITH, ANGELA JILL (LLPC, LLMFT)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:JILL
Last Name:SMITH
Suffix:
Gender:F
Credentials:LLPC, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 114
Mailing Address - Street 2:
Mailing Address - City:CASNOVIA
Mailing Address - State:MI
Mailing Address - Zip Code:49318-0114
Mailing Address - Country:US
Mailing Address - Phone:616-745-9743
Mailing Address - Fax:
Practice Address - Street 1:3300 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-2810
Practice Address - Country:US
Practice Address - Phone:616-942-7294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-17
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016543101YP2500X
MI4101006790106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist