Provider Demographics
NPI:1215418967
Name:HOLLYSMITH, HEATHER RAE (LMFT, MS)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:RAE
Last Name:HOLLYSMITH
Suffix:
Gender:F
Credentials:LMFT, MS
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:RAE
Other - Last Name:HOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4037 N MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-3717
Mailing Address - Country:US
Mailing Address - Phone:708-307-4583
Mailing Address - Fax:
Practice Address - Street 1:3354 N PAULINA ST STE 205
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-1087
Practice Address - Country:US
Practice Address - Phone:224-372-3963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166001457106H00000X
IL208000658106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist