Provider Demographics
NPI:1609687193
Name:SMITH, SYDNEY ELLESE
Entity type:Individual
Prefix:
First Name:SYDNEY
Middle Name:ELLESE
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 1:1480 W 82ND PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5273
Mailing Address - Country:US
Mailing Address - Phone:219-613-5686
Mailing Address - Fax:
Practice Address - Street 1:203 W FRANCISCAN DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-4802
Practice Address - Country:US
Practice Address - Phone:219-661-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-15
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN1196254106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician