Basic Information
| Provider Information | |||||||||
| NPI: | 1679863401 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | TABITHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 722 KEYSTONE LN | ||||||||
| Address2: | |||||||||
| City: | VERNON HILLS | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600612351 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654129377 | ||||||||
| FaxNumber: | 8667854924 | ||||||||
| Practice Location | |||||||||
| Address1: | 377 WESTRIDGE BLVD | ||||||||
| Address2: | |||||||||
| City: | GREENWOOD | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178884948 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2011 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225X00000X | 31005092A | IN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1679863401 | 05 | IN | MEDICAID |