Provider Demographics
NPI:1710488465
Name:SMITH, WANDA H
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:H
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 1:29714 FERNHILL DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-2026
Mailing Address - Country:US
Mailing Address - Phone:248-539-3184
Mailing Address - Fax:
Practice Address - Street 1:29200 SCHOOLCRAFT RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-2228
Practice Address - Country:US
Practice Address - Phone:734-512-3826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5201004608225XL0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XL0004XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistLow Vision