Provider Demographics
NPI:1588110092
Name:SMITH, PATRICIA LAWRENCE
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:LAWRENCE
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 1:3932 172ND ST
Mailing Address - Street 2:
Mailing Address - City:COUNTRY CLUB HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60478-4638
Mailing Address - Country:US
Mailing Address - Phone:773-842-5958
Mailing Address - Fax:708-991-7584
Practice Address - Street 1:3932 172ND ST
Practice Address - Street 2:
Practice Address - City:COUNTRY CLUB HILLS
Practice Address - State:IL
Practice Address - Zip Code:60478-4638
Practice Address - Country:US
Practice Address - Phone:773-842-5958
Practice Address - Fax:708-991-7584
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-26
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
252Y00000X
ILS530-6927-0828347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No252Y00000XAgenciesEarly Intervention Provider Agency