Provider Demographics
NPI:1821474040
Name:SMITH, BETTY JEAN (CMA)
Entity Type:Individual
Prefix:
First Name:BETTY
Middle Name:JEAN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20231 BLOOM ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48234-2408
Mailing Address - Country:US
Mailing Address - Phone:313-320-6688
Mailing Address - Fax:
Practice Address - Street 1:20300 BL:OOM ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48234-2408
Practice Address - Country:US
Practice Address - Phone:313-733-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIK5H2G6P4374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide