Provider Demographics
NPI:1629583042
Name:SMITH, QUINLAN ANNE
Entity Type:Individual
Prefix:
First Name:QUINLAN
Middle Name:ANNE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 S DIVISION AVE.
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507
Mailing Address - Country:US
Mailing Address - Phone:616-247-3815
Mailing Address - Fax:616-245-0450
Practice Address - Street 1:1939 S DIVISION AVE.
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507
Practice Address - Country:US
Practice Address - Phone:616-247-3815
Practice Address - Fax:616-245-0450
Is Sole Proprietor?:No
Enumeration Date:2017-12-07
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011042901041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical