Provider Demographics
NPI:1649648346
Name:SMYTH, TIMOTHY
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:SMYTH
Suffix:
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 1:333 N LA GRANGE RD
Mailing Address - Street 2:SUITE ONE
Mailing Address - City:LA GRANGE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60526-5646
Mailing Address - Country:US
Mailing Address - Phone:708-745-5277
Mailing Address - Fax:708-795-4834
Practice Address - Street 1:333 N LA GRANGE RD
Practice Address - Street 2:SUITE ONE
Practice Address - City:LA GRANGE PARK
Practice Address - State:IL
Practice Address - Zip Code:60526-5646
Practice Address - Country:US
Practice Address - Phone:708-745-5277
Practice Address - Fax:708-795-4834
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-11
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor