Provider Demographics
NPI:1952538704
Name:SMITH, MARY L
Entity Type:Individual
Prefix:
First Name:MARY
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 1:518 S EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-1322
Mailing Address - Country:US
Mailing Address - Phone:708-848-8514
Mailing Address - Fax:708-848-8514
Practice Address - Street 1:1 UNIVERSITY CIRCLE, WESTERN IL UNIV
Practice Address - Street 2:CNTR FOR BEST PRACTICES IN EARLY CHILDHOOD EDUCATION
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455
Practice Address - Country:US
Practice Address - Phone:800-701-0995
Practice Address - Fax:309-298-3066
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$AMedicare PIN