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General NPI Number Information
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NPI Number | 1518778117
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Entity Type | Individual
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Provider Name | THERESA TALIA SMITH
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Gender | Female
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Dates
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Enumeration Date | 01/14/2025
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 122 BAKER RD
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City | LAKE BLUFF
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State | IL
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Zip | 60044-1424
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Country | US
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Telephone | 630-486-7068
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Fax |
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Provider Business Mailing Address
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Address Line | 122 BAKER RD
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City | LAKE BLUFF
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State | IL
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Zip | 60044-1424
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Country | US
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Telephone | 630-486-7068
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 146N00000X
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Taxonomy Name | Basic Emergency Medical Technician
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License Number | 060991056
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License Number State | IL
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