Provider Demographics
NPI:1831580208
Name:SMITH, LATRINA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:LATRINA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 PICCADILLY LN
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1021
Mailing Address - Country:US
Mailing Address - Phone:630-253-6518
Mailing Address - Fax:
Practice Address - Street 1:605 PICCADILLY LN
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1021
Practice Address - Country:US
Practice Address - Phone:630-253-6518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490171981041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL47-2998431Medicaid
IL47-2998431Medicare UPIN
IL47-2998431Medicare PIN