Healthcare Provider Details

I. General information

NPI: 1104780816
Provider Name (Legal Business Name): KATLYN SMIGIELSKI MED/EDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

197 WINSTON DR
BOLINGBROOK IL
60440-1300
US

IV. Provider business mailing address

11321 SYCAMORE LN UNIT D
PALOS HILLS IL
60465-2572
US

V. Phone/Fax

Practice location:
  • Phone: 630-739-0185
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1233856
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: