Provider Demographics
NPI:1770082240
Name:SMITH, LEVI PATRICK
Entity type:Individual
Prefix:
First Name:LEVI
Middle Name:PATRICK
Last Name:SMITH
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 1:1909 WATERFORD DR.
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62703-5771
Mailing Address - Country:US
Mailing Address - Phone:217-416-8774
Mailing Address - Fax:
Practice Address - Street 1:5310 E WILLIAM STREET RD
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-1874
Practice Address - Country:US
Practice Address - Phone:217-422-6361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2023-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst