Provider Demographics
NPI:1699232702
Name:SMITH, CHARYL LYNN (MA, LPC, NCC)
Entity type:Individual
Prefix:MS
First Name:CHARYL
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, LPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23819 W MILL ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60544-3460
Mailing Address - Country:US
Mailing Address - Phone:815-955-8725
Mailing Address - Fax:
Practice Address - Street 1:23819 W MILL ST STE 3
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60544-3460
Practice Address - Country:US
Practice Address - Phone:815-955-8725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.013021101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health