1396375358 NPI number — MISS MALIYA SMITH MS, LPC., CKYT 200

Table of content: MISS MALIYA SMITH MS, LPC., CKYT 200 (NPI 1396375358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396375358 NPI number — MISS MALIYA SMITH MS, LPC., CKYT 200

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
MALIYA
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MS, LPC., CKYT 200
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396375358
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1101 CLIFFORD DR APT 6
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
URBANA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
61802-6815
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-560-5437
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1101 CLIFFORD DR APT 6
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
URBANA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61802-6815
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-560-5437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/17/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  178.015263 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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