MEDICARE: MR. ROBERT JOEL SMITH LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	149000032	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1623361	OTHER	IL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1114926235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT JOEL SMITH LCSW

Provider Business Mailing Address
First Line	:	5844 ELAINE DR STE 103
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61108-2494
Country	:	US
Telephone Number	:
Fax Number	:	779-220-2499

Provider Business Practice Location Address
First Line	:	500 LAKE COOK RD STE 350
Second Line	:
City	:	DEERFIELD
State	:	IL
Zip	:	60015-5268
Country	:	US
Telephone Number	:	847-363-5845
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/20/2005
Last Update Date	:	08/24/2022

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