Provider Demographics
NPI:1053740373
Name:SMITH, MONIQUE A (LCSW)
Entity type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:336 W 102ND ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60628-1915
Mailing Address - Country:US
Mailing Address - Phone:773-416-1913
Mailing Address - Fax:773-468-5484
Practice Address - Street 1:2656 W MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-1559
Practice Address - Country:US
Practice Address - Phone:773-267-5795
Practice Address - Fax:773-267-4787
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-06
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490054161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical