Provider Demographics
NPI:1114550688
Name:SMITH, WANDA DENISE (CPSYC HCPROF)
Entity Type:Individual
Prefix:
First Name:WANDA DENISE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CPSYC HCPROF
Other - Prefix:
Other - First Name:DENISE
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CPSYC HCPROF
Mailing Address - Street 1:11344 S HERMOSA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60643-4279
Mailing Address - Country:US
Mailing Address - Phone:331-643-5238
Mailing Address - Fax:
Practice Address - Street 1:17100 DIXIE HWY STE D
Practice Address - Street 2:
Practice Address - City:HAZEL CREST
Practice Address - State:IL
Practice Address - Zip Code:60429-1485
Practice Address - Country:US
Practice Address - Phone:331-643-5238
Practice Address - Fax:708-991-7320
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILKWN75FB9103TC2200X
IL8KUSC7H7172V00000X, 261QC1500X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36369473001Medicaid