Healthcare Provider Details

I. General information

NPI: 1871873893
Provider Name (Legal Business Name): CRYSTAL A SMITH IMFT, LCSW, IBHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: INTERNATIONAL BEHAVIORIAL HEALTH

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 01/05/2020
Certification Date: 01/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10448 S PULASKI RD SUITE 4
OAK LAWN IL
60453-4895
US

IV. Provider business mailing address

1342 W TAYLOR ST UNIT 302
CHICAGO IL
60607-4705
US

V. Phone/Fax

Practice location:
  • Phone: 312-834-3697
  • Fax:
Mailing address:
  • Phone: 312-554-9934
  • Fax: 877-211-1170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-125
License Number StateGU
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-4503
License Number StateHI
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW019175
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberGU-125
License Number StateGU
# 5
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberIBHC
License Number StateGU
# 6
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149014748
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: