Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 6401012401 | MI |
NPI | 1003270406 |
---|---|
Provider Name | Angela Smith |
First Address | Roseville, MI 48066-3286 |
Second Address | Roseville, MI 48066-3286 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2016 |
Last Update Date | 12/04/2016 |