Healthcare Provider Details

I. General information

NPI: 1326605247
Provider Name (Legal Business Name): MICHELLE SMEKENS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2019
Last Update Date: 05/19/2022
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 GREEN BAY RD FL 2
HIGHWOOD IL
60040-1703
US

IV. Provider business mailing address

37194 N DILLON CT
LAKE VILLA IL
60046-1702
US

V. Phone/Fax

Practice location:
  • Phone: 847-235-2139
  • Fax:
Mailing address:
  • Phone: 224-643-7174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number10-1222
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164007177
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: