Provider Demographics
NPI:1053540559
Name:SMITH, MARCIE J (LCPC, NCC)
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:J
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCPC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:226 STATE ST
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1864
Mailing Address - Country:US
Mailing Address - Phone:630-587-3777
Mailing Address - Fax:630-587-3791
Practice Address - Street 1:226 STATE ST
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:IL
Practice Address - Zip Code:60174-1864
Practice Address - Country:US
Practice Address - Phone:630-587-3777
Practice Address - Fax:630-587-3791
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-07
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180002075101YP2500X
IL101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1912078262OtherGROUP