Provider Demographics
NPI:1710463864
Name:SMITH, LENA GRACE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LENA
Middle Name:GRACE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2542
Mailing Address - Country:US
Mailing Address - Phone:847-624-2698
Mailing Address - Fax:
Practice Address - Street 1:1316 BOND ST STE 116
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60563-6526
Practice Address - Country:US
Practice Address - Phone:630-357-9699
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2019-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.014931235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist