Provider Demographics
NPI:1780958769
Name:SMITH, KELLY M (BS, CBIS EXP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:BS, CBIS EXP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11415 LAUDERDALE CT
Mailing Address - Street 2:
Mailing Address - City:PINCKNEY
Mailing Address - State:MI
Mailing Address - Zip Code:48169-9535
Mailing Address - Country:US
Mailing Address - Phone:734-878-2919
Mailing Address - Fax:
Practice Address - Street 1:2880 RENFREW ST.
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48105-1454
Practice Address - Country:US
Practice Address - Phone:734-649-6749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-08
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1018225400000X
MI1018225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner