Provider Demographics
NPI:1558831081
Name:SMITH, THIERA (LAC)
Entity Type:Individual
Prefix:
First Name:THIERA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2128 N MAPLEWOOD AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4116
Mailing Address - Country:US
Mailing Address - Phone:773-988-7370
Mailing Address - Fax:
Practice Address - Street 1:2128 N MAPLEWOOD AVE APT 1
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4116
Practice Address - Country:US
Practice Address - Phone:773-988-7370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-27
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.001358171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist