Provider Demographics
NPI:1538561873
Name:PATRICO-SMITH, TARA M (LMSW)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:M
Last Name:PATRICO-SMITH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9650 WAYNE RD
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-1551
Mailing Address - Country:US
Mailing Address - Phone:734-942-4857
Mailing Address - Fax:
Practice Address - Street 1:9650 WAYNE RD
Practice Address - Street 2:
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-1551
Practice Address - Country:US
Practice Address - Phone:734-942-4857
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010970601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical