Provider Demographics
NPI:1437790540
Name:SMITH, RICKY BRIAN (LMFT)
Entity Type:Individual
Prefix:MR
First Name:RICKY
Middle Name:BRIAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 LAKE ST APT 607
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1498
Mailing Address - Country:US
Mailing Address - Phone:312-307-3935
Mailing Address - Fax:
Practice Address - Street 1:1000 LAKE ST APT 607
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1498
Practice Address - Country:US
Practice Address - Phone:312-620-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-01
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208.000749101YM0800X
IL166001501106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL208.000749OtherILLINOIS AMFT LICENSE