Provider Demographics
NPI:1295480655
Name:SMITH, LATIKA R (LMT)
Entity type:Individual
Prefix:
First Name:LATIKA
Middle Name:R
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:19315 ANNCHESTER RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-2725
Mailing Address - Country:US
Mailing Address - Phone:313-469-4762
Mailing Address - Fax:
Practice Address - Street 1:23077 GREENFIELD RD STE 250
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-3768
Practice Address - Country:US
Practice Address - Phone:248-557-7336
Practice Address - Fax:248-557-4544
Is Sole Proprietor?:No
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008449225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist