Provider Demographics
NPI:1326859422
Name:SMITH, CHARLOTTE M (LPC)
Entity type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:M
Last Name:SMITH
Suffix:
Gender:
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1517 W HOLLY HEDGES DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4168
Mailing Address - Country:US
Mailing Address - Phone:847-977-7647
Mailing Address - Fax:
Practice Address - Street 1:1517 W HOLLY HEDGES DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4168
Practice Address - Country:US
Practice Address - Phone:847-977-7647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.021313101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty