Provider Demographics
NPI:1457848715
Name:SMITH, MARYEM
Entity Type:Individual
Prefix:
First Name:MARYEM
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 1:8200 TODD LN
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IL
Mailing Address - Zip Code:62298-5422
Mailing Address - Country:US
Mailing Address - Phone:781-330-9618
Mailing Address - Fax:
Practice Address - Street 1:8200 TODD LN
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-5422
Practice Address - Country:US
Practice Address - Phone:781-330-9618
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-21
Last Update Date:2018-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist