Provider Demographics
NPI:1699163451
Name:SMOTZER, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:SMOTZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 GRAPE VINE TRL
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:IL
Mailing Address - Zip Code:60543-6017
Mailing Address - Country:US
Mailing Address - Phone:630-661-7253
Mailing Address - Fax:855-765-7549
Practice Address - Street 1:470 GRAPE VINE TRL
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:IL
Practice Address - Zip Code:60543-6017
Practice Address - Country:US
Practice Address - Phone:630-661-7253
Practice Address - Fax:855-765-7549
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2015-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2170001522355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant