Healthcare Provider Details

I. General information

NPI: 1659198265
Provider Name (Legal Business Name): KAITLYN A SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 CREAMERY HILL RD
DALLAS CITY IL
62330-1216
US

IV. Provider business mailing address

921 CREAMERY HILL RD
DALLAS CITY IL
62330-1216
US

V. Phone/Fax

Practice location:
  • Phone: 217-852-3201
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number1193153
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: