Provider Demographics
NPI:1396557112
Name:SMITH, MARVA L
Entity type:Individual
Prefix:
First Name:MARVA
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13604 S MONTICELLO AVE
Mailing Address - Street 2:
Mailing Address - City:ROBBINS
Mailing Address - State:IL
Mailing Address - Zip Code:60472-1526
Mailing Address - Country:US
Mailing Address - Phone:708-639-8772
Mailing Address - Fax:
Practice Address - Street 1:13604 S MONTICELLO AVE
Practice Address - Street 2:
Practice Address - City:ROBBINS
Practice Address - State:IL
Practice Address - Zip Code:60472-1526
Practice Address - Country:US
Practice Address - Phone:708-639-8772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician