Provider Demographics
NPI:1710476940
Name:CLINESMITH, KAILEY CHRISTIN (BSW)
Entity Type:Individual
Prefix:
First Name:KAILEY
Middle Name:CHRISTIN
Last Name:CLINESMITH
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:863 N PINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:ESSEXVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48732-2159
Mailing Address - Country:US
Mailing Address - Phone:989-928-3566
Mailing Address - Fax:989-391-9596
Practice Address - Street 1:863 N PINE RD STE A
Practice Address - Street 2:
Practice Address - City:ESSEXVILLE
Practice Address - State:MI
Practice Address - Zip Code:48732-2159
Practice Address - Country:US
Practice Address - Phone:989-928-3566
Practice Address - Fax:989-391-9596
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI101YA0400XMedicaid