1669057287 NPI number — MRS. SALLY ANN SMITH LMSW, BCBA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669057287 NPI number — MRS. SALLY ANN SMITH LMSW, BCBA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
SALLY
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW, BCBA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FREDERICK
Provider Other First Name:
SALLY
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669057287
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 RADNY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOWELL
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49331-9131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-901-7180
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5242 PLAINFIELD AVE NE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49525-1084
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-363-2200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801084828 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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