Provider Demographics
NPI:1629648050
Name:SMART, DEBORAH A
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:A
Last Name:SMART
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 1:53 W JACKSON BLVD STE 510
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60604-3434
Mailing Address - Country:US
Mailing Address - Phone:312-600-0876
Mailing Address - Fax:
Practice Address - Street 1:53 W JACKSON BLVD STE 510
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60604-3434
Practice Address - Country:US
Practice Address - Phone:312-600-0876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-28
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILNA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS56316152871OtherDRIVERS LICENSE