Provider Demographics
NPI:1679863401
Name:SMITH, TABITHA
Entity type:Individual
Prefix:
First Name:TABITHA
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 KEYSTONE LN
Mailing Address - Street 2:
Mailing Address - City:VERNON HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60061-2351
Mailing Address - Country:US
Mailing Address - Phone:765-412-9377
Mailing Address - Fax:866-785-4924
Practice Address - Street 1:377 WESTRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142
Practice Address - Country:US
Practice Address - Phone:317-888-4948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-13
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31005092A225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1679863401Medicaid