MEDICARE: COLLEENA SUE SMITH

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	103K00000X	Behavior Analyst	1-24-74573	IL

General Provider Information

NPI Number	:	1851850242
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	COLLEENA SUE SMITH

Provider Business Mailing Address
First Line	:	991 OAK CREEK DR
Second Line	:
City	:	LOMBARD
State	:	IL
Zip	:	60148-6408
Country	:	US
Telephone Number	:	847-465-9556
Fax Number	:

Provider Business Practice Location Address
First Line	:	7177 CRIMSON RIDGE DR STE 10
Second Line	:
City	:	ROCKFORD
State	:	IL
Zip	:	61107-6235
Country	:	US
Telephone Number	:	847-465-9556
Fax Number	:

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

Provider Enumeration Date	:	03/15/2019
Last Update Date	:	07/30/2024

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Directions to “ COLLEENA SUE SMITH ” Practice Location

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