Provider Demographics
NPI:1407624109
Name:SMITH, AMBER
Entity Type:Individual
Prefix:
First Name:AMBER
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 1:1645 W JACKSON BLVD STE 602
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2847
Mailing Address - Country:US
Mailing Address - Phone:773-642-6781
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD STE 602
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2847
Practice Address - Country:US
Practice Address - Phone:773-642-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.105537104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker