Provider Demographics
NPI:1720558059
Name:SMITH, CELESTE JEAN (MED, LPC)
Entity Type:Individual
Prefix:
First Name:CELESTE
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 W WALTON BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-4191
Mailing Address - Country:US
Mailing Address - Phone:810-545-8308
Mailing Address - Fax:
Practice Address - Street 1:4000 W WALTON BLVD STE A
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329
Practice Address - Country:US
Practice Address - Phone:810-545-8308
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016468101Y00000X
MI640101753101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor