=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356706162
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LATRINA SMITH & ASSOCIATES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2015
-----------------------------------------------------
Last Update Date | 06/20/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 682 W BOUGHTON RD UNIT D
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-5700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 331-333-9074
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 605 PICCADILLY LN
-----------------------------------------------------
City | BOLINGBROOK
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60440-1021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 630-253-6518
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LICENSE CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | MRS. LATRINA SMITH
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 630-253-6518
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 149017198
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------