Provider Demographics
NPI:1598375552
Name:SMITH, KRISTY (LCPC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:WATSEKA
Mailing Address - State:IL
Mailing Address - Zip Code:60970-1228
Mailing Address - Country:US
Mailing Address - Phone:815-383-7669
Mailing Address - Fax:
Practice Address - Street 1:525 E NORTH ST
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1185
Practice Address - Country:US
Practice Address - Phone:888-870-1775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180014855101YP2500X
IL178012642101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health