Provider Demographics
NPI:1821720780
Name:SMITH, ALLYSON JULIENNE
Entity Type:Individual
Prefix:
First Name:ALLYSON
Middle Name:JULIENNE
Last Name:SMITH
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 1:5448 TALON TRL
Mailing Address - Street 2:
Mailing Address - City:MACHESNEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:61115-8327
Mailing Address - Country:US
Mailing Address - Phone:815-595-3978
Mailing Address - Fax:
Practice Address - Street 1:1639 N ALPINE RD STE 260
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-1481
Practice Address - Country:US
Practice Address - Phone:815-505-3978
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty