Provider Demographics
NPI:1952016024
Name:SMITH, NICHOLAS JOHN
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOHN
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 1:799 N LATSON RD
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-8595
Mailing Address - Country:US
Mailing Address - Phone:810-222-9469
Mailing Address - Fax:
Practice Address - Street 1:3471 E GRAND RIVER AVE # 106
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-8552
Practice Address - Country:US
Practice Address - Phone:800-789-3062
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician