Provider Demographics
NPI:1780935536
Name:SMITH, KIM MARIE (PHD)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20590 WAYLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3157
Mailing Address - Country:US
Mailing Address - Phone:248-557-3820
Mailing Address - Fax:
Practice Address - Street 1:31800 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 201
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-1655
Practice Address - Country:US
Practice Address - Phone:248-557-3820
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-19
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015598103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical