Provider Demographics
NPI:1699205567
Name:SMITH, MICHAEL LEE (BA,JD)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:BA,JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:BEARDSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:62618-1263
Mailing Address - Country:US
Mailing Address - Phone:217-323-2980
Mailing Address - Fax:217-323-3731
Practice Address - Street 1:121 E 2ND ST
Practice Address - Street 2:
Practice Address - City:BEARDSTOWN
Practice Address - State:IL
Practice Address - Zip Code:62618-1263
Practice Address - Country:US
Practice Address - Phone:217-323-2980
Practice Address - Fax:217-323-3731
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)