1104435478 NPI number — MRS. ELIZABETH ANN SMITH LPC, ATR

Table of content: MRS. ELIZABETH ANN SMITH LPC, ATR (NPI 1104435478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104435478 NPI number — MRS. ELIZABETH ANN SMITH LPC, ATR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMITH
Provider First Name:
ELIZABETH
Provider Middle Name:
ANN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC, ATR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VANDERMOLEN
Provider Other First Name:
ELIZABETH
Provider Other Middle Name:
ANN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104435478
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 S FRONTAGE RD STE 320
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BURR RIDGE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60527-6953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-337-8006
Provider Business Mailing Address Fax Number:
630-537-1241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 S FRONTAGE RD STE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURR RIDGE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60527-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-337-8006
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/23/2020

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:  178015418 , 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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