Provider Demographics
NPI:1164109591
Name:SMITH, WILLIAM KELVYN (EDD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KELVYN
Last Name:SMITH
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 PICCADILLY LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1021
Mailing Address - Country:US
Mailing Address - Phone:630-673-2040
Mailing Address - Fax:
Practice Address - Street 1:605 PICCADILLY LN
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1021
Practice Address - Country:US
Practice Address - Phone:630-673-2040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490094351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical