Provider Demographics
NPI:1558573154
Name:SMITH, DIANE SHARON (PHD MSW APRN BC CNS)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:SHARON
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD MSW APRN BC CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1506 LOCHMOOR BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-4016
Mailing Address - Country:US
Mailing Address - Phone:313-885-0099
Mailing Address - Fax:313-882-7424
Practice Address - Street 1:119 KERCHEVAL AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236
Practice Address - Country:US
Practice Address - Phone:313-881-2010
Practice Address - Fax:313-882-7424
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010171131041C0700X
MI6301007629103TC0700X
MI110675363LP0808X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Not Answered363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Not Answered364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301007629OtherCLINICAL PSYCHOLOGIST
MI5008661290OtherBLUE CROSS BLUE SHIELD
MI6801017113OtherCMSW
MI26500001Medicare ID - Type Unspecified
MI5008661290OtherBLUE CROSS BLUE SHIELD
MIS44524Medicare UPIN