Provider Demographics
NPI:1922297050
Name:ROLANDA M SMITH
Entity Type:Organization
Organization Name:ROLANDA M SMITH
Other - Org Name:R A W PROFESSIONAL SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEVELOPMENTAL THERAPIST
Authorized Official - Prefix:MISS
Authorized Official - First Name:ROLANDA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-201-0058
Mailing Address - Street 1:430 E 162ND ST STE 430
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-2258
Mailing Address - Country:US
Mailing Address - Phone:708-201-0058
Mailing Address - Fax:888-646-5822
Practice Address - Street 1:430 E 162ND ST STE 430
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-2258
Practice Address - Country:US
Practice Address - Phone:708-201-0058
Practice Address - Fax:888-646-5822
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1000444156276201Medicaid