Provider Demographics
NPI:1841739133
Name:SMITH, RAYMOND LEE
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:LEE
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21885 DUNHAM RD STE 1
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-1030
Mailing Address - Country:US
Mailing Address - Phone:586-469-5950
Mailing Address - Fax:586-469-6637
Practice Address - Street 1:12220 E 13 MILE RD STE 300
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-5000
Practice Address - Country:US
Practice Address - Phone:586-573-1810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-20
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301016719103T00000X
MI21179070632103T00000X
MI6401019553101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor