Basic Information
Provider Information
NPI: 1003155656
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: SMITH
FirstName: NICHOLAS
MiddleName: JOSEPH
NamePrefix: MR.
NameSuffix:  
Credential: L.P.C.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 555 THORNHILL DR
Address2: APT. 214
City: CAROL STREAM
State: IL
PostalCode: 601882760
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 24020 W RIVERWALK CT
Address2: SUITE 100
City: PLAINFIELD
State: IL
PostalCode: 605447103
CountryCode: US
TelephoneNumber: 8155778970
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/01/2013
LastUpdateDate: 02/01/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
101YP2500X178.008678ILY Behavioral Health & Social Service ProvidersCounselorProfessional

No ID Information.


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