Provider Demographics
NPI:1013043173
Name:SMITH, BETTY B (LCSW, BCD)
Entity Type:Individual
Prefix:MS
First Name:BETTY
Middle Name:B
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW, BCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8204 S KENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60619-3440
Mailing Address - Country:US
Mailing Address - Phone:773-731-3006
Mailing Address - Fax:773-731-0795
Practice Address - Street 1:30 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1518
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60602-3402
Practice Address - Country:US
Practice Address - Phone:312-201-1301
Practice Address - Fax:773-731-0795
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
202450Medicare ID - Type Unspecified