Provider Demographics
NPI:1194197749
Name:SMITH, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
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 1:3543 N PULASKI RD
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60641-3945
Mailing Address - Country:US
Mailing Address - Phone:312-504-7567
Mailing Address - Fax:312-448-8574
Practice Address - Street 1:3543 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-3945
Practice Address - Country:US
Practice Address - Phone:312-504-7567
Practice Address - Fax:312-448-8574
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2022-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150101300104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1194197749OtherNPI