Provider Demographics
NPI:1326364845
Name:SMITH, STEPHEN WILLIAM (MS,LPC,CADC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:WILLIAM
Last Name:SMITH
Suffix:
Gender:M
Credentials:MS,LPC,CADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 N MULFORD RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-3877
Mailing Address - Country:US
Mailing Address - Phone:815-708-4768
Mailing Address - Fax:815-394-1401
Practice Address - Street 1:1021 N MULFORD RD
Practice Address - Street 2:SUITE 1
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-3877
Practice Address - Country:US
Practice Address - Phone:815-708-4768
Practice Address - Fax:815-394-1401
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-08
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL25850101YA0400X
IL178.006369101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)