Provider Demographics
NPI:1043793946
Name:SMOLAK, KATHRYN
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:SMOLAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E ALEXANDER ST
Mailing Address - Street 2:
Mailing Address - City:ENERGY
Mailing Address - State:IL
Mailing Address - Zip Code:62933-5008
Mailing Address - Country:US
Mailing Address - Phone:618-727-1049
Mailing Address - Fax:
Practice Address - Street 1:300 E ALEXANDER ST
Practice Address - Street 2:
Practice Address - City:ENERGY
Practice Address - State:IL
Practice Address - Zip Code:62933-5008
Practice Address - Country:US
Practice Address - Phone:618-727-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-07
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242004984235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist