Provider Demographics
NPI:1710462569
Name:SMITH, COY
Entity Type:Individual
Prefix:
First Name:COY
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8600 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2142
Mailing Address - Country:US
Mailing Address - Phone:313-875-7601
Mailing Address - Fax:313-313-8711
Practice Address - Street 1:8600 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2142
Practice Address - Country:US
Practice Address - Phone:313-875-7601
Practice Address - Fax:313-871-1891
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011026631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical