Provider Demographics
NPI:1649762386
Name:SMITH, LORRAINE E (ATC)
Entity type:Individual
Prefix:MISS
First Name:LORRAINE
Middle Name:E
Last Name:SMITH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9764 DRUM HILL RD
Mailing Address - Street 2:
Mailing Address - City:MASCOUTAH
Mailing Address - State:IL
Mailing Address - Zip Code:62258-4528
Mailing Address - Country:US
Mailing Address - Phone:217-473-6963
Mailing Address - Fax:
Practice Address - Street 1:1313 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MASCOUTAH
Practice Address - State:IL
Practice Address - Zip Code:62258-1065
Practice Address - Country:US
Practice Address - Phone:618-566-8523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-30
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0038512255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer