Provider Demographics
NPI:1790838811
Name:SMITH, CHARLES MICHAEL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:MICHAEL
Last Name:SMITH
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 N 2ND ST
Mailing Address - Street 2:SUITE # 304
Mailing Address - City:NILES
Mailing Address - State:MI
Mailing Address - Zip Code:49120-2258
Mailing Address - Country:US
Mailing Address - Phone:269-687-9364
Mailing Address - Fax:269-782-5344
Practice Address - Street 1:333 N 2ND ST
Practice Address - Street 2:SUITE # 304
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-2258
Practice Address - Country:US
Practice Address - Phone:269-687-9364
Practice Address - Fax:269-782-5344
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008141103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI68-0-A1-3124OtherBCBSN PARTICIPATING PROV
MI0-A1-31242-682Medicare ID - Type UnspecifiedNON-PARTICIPATING