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 1:334 JARVIS ST APT 109
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8132
Practice Address - Country:US
Practice Address - Phone:819-588-3374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-09
Last Update Date:2025-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362010146103T00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician