Provider Demographics
NPI:1861839300
Name:SMITH, RANDAL GENE (CADC, AAS)
Entity Type:Individual
Prefix:MR
First Name:RANDAL
Middle Name:GENE
Last Name:SMITH
Suffix:
Gender:M
Credentials:CADC, AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 HUCKLEBERRY LN
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2358
Mailing Address - Country:US
Mailing Address - Phone:810-962-5139
Mailing Address - Fax:
Practice Address - Street 1:529 MARTIN LUTHER KING JUNIOR BLVD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48502-2002
Practice Address - Country:US
Practice Address - Phone:810-238-0483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-23
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICADC101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)