Healthcare Provider Details

I. General information

NPI: 1255814620
Provider Name (Legal Business Name): KEVIN SMERKO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2018
Last Update Date: 09/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2704 N MAIN ST
ROCKFORD IL
61103-3112
US

IV. Provider business mailing address

1021 N MULFORD RD
ROCKFORD IL
61107-3877
US

V. Phone/Fax

Practice location:
  • Phone: 815-968-9300
  • Fax: 815-720-4950
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number178008791
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: