Provider Demographics
NPI:1972036994
Name:SMITH, THOMAS SR
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:SMITH
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:369 E SIBLEY BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:IL
Mailing Address - Zip Code:60426-2535
Mailing Address - Country:US
Mailing Address - Phone:888-205-5532
Mailing Address - Fax:
Practice Address - Street 1:369 E SIBLEY BLVD
Practice Address - Street 2:
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-2530
Practice Address - Country:US
Practice Address - Phone:888-205-5532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-06
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL106S00000X
IL1093075301106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1093075301Medicaid