=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285038463
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZAKETTE SMITH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2014
-----------------------------------------------------
Last Update Date | 10/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3615 PARK DR
-----------------------------------------------------
City | OLYMPIA FIELDS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60461-1186
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-506-6321
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 561 GORDON AVE
-----------------------------------------------------
City | CALUMET CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60409-3528
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-459-3004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | S53099276808
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------