Provider Demographics
NPI:1871873893
Name:SMITH, CRYSTAL A (IMFT, LCSW, IBHC)
Entity type:Individual
Prefix:MS
First Name:CRYSTAL
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:IMFT, LCSW, IBHC
Other - Prefix:
Other - First Name:INTERNATIONAL
Other - Middle Name:
Other - Last Name:BEHAVIORIAL HEALTH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1342 W TAYLOR ST UNIT 302
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-4705
Mailing Address - Country:US
Mailing Address - Phone:312-554-9934
Mailing Address - Fax:877-211-1170
Practice Address - Street 1:10448 S PULASKI RD
Practice Address - Street 2:SUITE 4
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-4895
Practice Address - Country:US
Practice Address - Phone:312-834-3697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2020-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GULPC-125101YP2500X
HILCSW-45031041C0700X
PACW0191751041C0700X
GUGU-125106H00000X
GUIBHC171000000X
IL1490147481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171000000XOther Service ProvidersMilitary Health Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL8367001Medicaid