1164703567 NPI number — MR. ROBERT DAVID SMOLA MSW, LCSW

Table of content: MR. ROBERT DAVID SMOLA MSW, LCSW (NPI 1164703567)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164703567 NPI number — MR. ROBERT DAVID SMOLA MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SMOLA
Provider First Name:
ROBERT
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
M

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:
1164703567
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1859 BUCKINGHAM AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTCHESTER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60154-4268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-574-8980
Provider Business Mailing Address Fax Number:
708-680-3122

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1600 WESTCHESTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTCHESTER
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60154-4362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-574-8980
Provider Business Practice Location Address Fax Number:
708-680-3122
Provider Enumeration Date:
08/30/2011

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: 1041C0700X , with the licence number:  149.009477 , 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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