Provider Demographics
NPI:1669057287
Name:SMITH, SALLY ANN (LMSW, BCBA)
Entity type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:ANN
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMSW, BCBA
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:ANN
Other - Last Name:FREDERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19 RADNY DR
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:49331-9131
Mailing Address - Country:US
Mailing Address - Phone:616-901-7180
Mailing Address - Fax:
Practice Address - Street 1:5242 PLAINFIELD AVE NE STE A
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-1084
Practice Address - Country:US
Practice Address - Phone:616-363-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010848281041C0700X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical