Provider Demographics
NPI:1801121033
Name:SMITH, KRISSIE FERNANDEZ (PHD)
Entity type:Individual
Prefix:DR
First Name:KRISSIE
Middle Name:FERNANDEZ
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:CRISTINA
Other - Middle Name:
Other - Last Name:FERNANDEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:8303 PLATT RD
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-9773
Mailing Address - Country:US
Mailing Address - Phone:734-925-4802
Mailing Address - Fax:734-429-3734
Practice Address - Street 1:8303 PLATT RD
Practice Address - Street 2:
Practice Address - City:SALINE
Practice Address - State:MI
Practice Address - Zip Code:48176-9773
Practice Address - Country:US
Practice Address - Phone:734-295-4802
Practice Address - Fax:734-429-3734
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-06
Last Update Date:2009-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013599103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic