Provider Demographics
NPI:1336679455
Name:SMITH, KRISTINE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:725 SCHOOL ST STE A
Mailing Address - Street 2:
Mailing Address - City:MORRIS
Mailing Address - State:IL
Mailing Address - Zip Code:60450-1207
Mailing Address - Country:US
Mailing Address - Phone:815-941-9124
Mailing Address - Fax:815-941-4363
Practice Address - Street 1:409 N US ROUTE 53
Practice Address - Street 2:
Practice Address - City:GARDNER
Practice Address - State:IL
Practice Address - Zip Code:60424
Practice Address - Country:US
Practice Address - Phone:815-237-0413
Practice Address - Fax:815-237-0514
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2020-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150015098104100000X
IL1490195651041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker