Provider Demographics
NPI:1720152119
Name:SMEBY, VICKI LYNN NELSON (MA LLP)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:LYNN NELSON
Last Name:SMEBY
Suffix:
Gender:F
Credentials:MA LLP
Other - Prefix:MS
Other - First Name:VICKI
Other - Middle Name:NELSON
Other - Last Name:SMEBY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA LLP
Mailing Address - Street 1:2208 STRATFORD CT SE
Mailing Address - Street 2:
Mailing Address - City:EAST GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4133
Mailing Address - Country:US
Mailing Address - Phone:616-460-1819
Mailing Address - Fax:616-942-9490
Practice Address - Street 1:4519 CASCADE RD SE
Practice Address - Street 2:BLDG 2 STE 1
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3666
Practice Address - Country:US
Practice Address - Phone:616-460-1819
Practice Address - Fax:616-942-9490
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010861103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling