Basic Information
| Provider Information | |||||||||
| NPI: | 1942666045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | OLIVIA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 LEE ST | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | DES PLAINES | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600166532 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774864140 | ||||||||
| FaxNumber: | 8474864145 | ||||||||
| Practice Location | |||||||||
| Address1: | 12075 CORPORATE PKWY STE 110 | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530922664 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774864140 | ||||||||
| FaxNumber: | 8474864145 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2016 | ||||||||
| LastUpdateDate: | 01/09/2018 | ||||||||
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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 | 103K00000X | 1-15-19887 | IL | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 129-140 | 01 | WI | STATE OF WISCONSIN | OTHER |