Provider Demographics
NPI:1023475761
Name:SMITH, AMY SUE (LMSW)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:SUE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:SUE
Other - Last Name:COLLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:3111 ELECTRIC AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-8127
Mailing Address - Country:US
Mailing Address - Phone:810-966-7830
Mailing Address - Fax:810-985-7620
Practice Address - Street 1:3111 ELECTRIC AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-8127
Practice Address - Country:US
Practice Address - Phone:810-966-7830
Practice Address - Fax:810-985-7620
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401004469101YP2500X
MI68010577671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional