Provider Demographics
NPI:1659956167
Name:SMITH, JUSTINE NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4061 S WEST COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:MI
Mailing Address - Zip Code:48889-9617
Mailing Address - Country:US
Mailing Address - Phone:616-920-9025
Mailing Address - Fax:989-831-7578
Practice Address - Street 1:4061 S WEST COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:SUMNER
Practice Address - State:MI
Practice Address - Zip Code:48889-9617
Practice Address - Country:US
Practice Address - Phone:616-920-9025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical