Provider Demographics
NPI:1912592114
Name:SMITH, ALEXIS ZACHERY
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:ZACHERY
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:334 JARVIS ST APT 209
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8133
Mailing Address - Country:US
Mailing Address - Phone:819-588-3374
Mailing Address - Fax:
Practice Address - Street 1:1055 CORNELL RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1657
Practice Address - Country:US
Practice Address - Phone:734-487-2890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-09
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician