Provider Demographics
NPI:1417109406
Name:SMITH, CRYSTAL LAUREN (BC-DMT, LCPC)
Entity Type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LAUREN
Last Name:SMITH
Suffix:
Gender:F
Credentials:BC-DMT, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 CHURCH ST
Mailing Address - Street 2:SUITE 510
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201-4508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:636 CHURCH ST
Practice Address - Street 2:SUITE 510
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4508
Practice Address - Country:US
Practice Address - Phone:773-817-2797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-21
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006725101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional