Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YP2500X | Professional Counselor | 180002075 | IL |
N | 101YS0200X | School Counselor | IL |
NPI | 1053540559 |
---|---|
Provider Name | Marcie J Smith |
First Address | St Charles, IL 60174-1864 |
Second Address | St Charles, IL 60174-1864 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2009 |
Last Update Date | 13/08/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1912078262 | GROUP (01) | IL |