Provider Demographics
NPI:1740701036
Name:SMITH, GINA (LCPC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9405 BORMET DR STE 6
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-7400
Mailing Address - Country:US
Mailing Address - Phone:708-290-9020
Mailing Address - Fax:
Practice Address - Street 1:9405 BORMET DR STE 6
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-7400
Practice Address - Country:US
Practice Address - Phone:708-290-9020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional