Provider Demographics
NPI:1679607766
Name:SMITH, ERIN KATHLEEN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:ERIN
Middle Name:KATHLEEN
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24000 S WILLIAM DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-8459
Mailing Address - Country:US
Mailing Address - Phone:317-902-4255
Mailing Address - Fax:
Practice Address - Street 1:24000 S WILLIAM DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-8459
Practice Address - Country:US
Practice Address - Phone:317-902-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146012852235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200812710Medicaid