Provider Demographics
NPI:1043712433
Name:SMITH, ELIZABETH NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11800 S 75TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1064
Mailing Address - Country:US
Mailing Address - Phone:708-671-8440
Mailing Address - Fax:
Practice Address - Street 1:11800 S 75TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1064
Practice Address - Country:US
Practice Address - Phone:708-671-8440
Practice Address - Fax:708-671-8664
Is Sole Proprietor?:No
Enumeration Date:2018-03-01
Last Update Date:2020-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043115A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL071.010238OtherLICENSE NUMBER