Provider Demographics
NPI:1679386577
Name:SMITH, KELLY NICOLE (LMFT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NICOLE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 EXECUTIVE PL STE 501
Mailing Address - Street 2:
Mailing Address - City:GENEVA
Mailing Address - State:IL
Mailing Address - Zip Code:60134-2482
Mailing Address - Country:US
Mailing Address - Phone:630-232-7457
Mailing Address - Fax:
Practice Address - Street 1:1250 EXECUTIVE PL STE 501
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-2482
Practice Address - Country:US
Practice Address - Phone:630-232-7457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL166.001850106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist