Provider Demographics
NPI:1881470763
Name:SMITH, NESITA L
Entity type:Individual
Prefix:
First Name:NESITA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 N HARLEM AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-1250
Mailing Address - Country:US
Mailing Address - Phone:872-946-5656
Mailing Address - Fax:
Practice Address - Street 1:1515 N HARLEM AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-1250
Practice Address - Country:US
Practice Address - Phone:872-946-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
ILRBT-21-192954106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician