MEDICARE: MRS. MARY ANN CUSHING SMITH L.C.P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	180-0014100	IL

General Provider Information

NPI Number	:	1063697696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ANN CUSHING SMITH L.C.P.C.

Provider Business Mailing Address
First Line	:	5116 FOREST AVE
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-4658
Country	:	US
Telephone Number	:	630-968-6727
Fax Number	:	630-964-1126

Provider Business Practice Location Address
First Line	:	5116 FOREST AVE
Second Line	:
City	:	DOWNERS GROVE
State	:	IL
Zip	:	60515-4658
Country	:	US
Telephone Number	:	630-968-6727
Fax Number	:	630-964-1126

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/02/2008
Last Update Date	:	01/02/2008

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