MEDICARE: SMEBAKKEN, LTD.

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	251S00000X	Community/Behavioral Health Agency		IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1609875616	OTHER	IL	NPI

General Provider Information

NPI Number	:	1306036918
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMEBAKKEN, LTD.

Provider Business Mailing Address
First Line	:	125 S WILKE RD STE 200A
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1522
Country	:	US
Telephone Number	:	847-870-0771
Fax Number	:

Provider Business Practice Location Address
First Line	:	125 S WILKE RD STE 200A
Second Line	:
City	:	ARLINGTON HEIGHTS
State	:	IL
Zip	:	60005-1522
Country	:	US
Telephone Number	:	847-870-0771
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	LESSI SMEBAKKEN
Credential	:	L.C.S.W., .CA.D.C.
Telephone Number	:	847-870-0771

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	07/30/2007

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