Provider Demographics
NPI:1689391641
Name:SMITH, SIEMONE (LCPC)
Entity Type:Individual
Prefix:
First Name:SIEMONE
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 1:137 N OAK PARK AVE STE 329
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60301-1375
Mailing Address - Country:US
Mailing Address - Phone:773-340-2336
Mailing Address - Fax:
Practice Address - Street 1:137 N OAK PARK AVE STE 329
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60301-1375
Practice Address - Country:US
Practice Address - Phone:773-340-2336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.014703101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
1234567OtherN/A