Provider Demographics
NPI:1124364963
Name:SMITH, JUANITA LOUISE
Entity Type:Individual
Prefix:MS
First Name:JUANITA
Middle Name:LOUISE
Last Name:SMITH
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 1:939 HONEY LN
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-1329
Mailing Address - Country:US
Mailing Address - Phone:708-674-4837
Mailing Address - Fax:708-672-9883
Practice Address - Street 1:939 HONEY LN
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-1329
Practice Address - Country:US
Practice Address - Phone:708-674-4837
Practice Address - Fax:708-672-9883
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2299795101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool