Provider Demographics
NPI:1487101564
Name:SMITH, KRYSTAL ANN
Entity type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:ANN
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 1:12151 REGENCY PKWY STE 12169
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-7644
Mailing Address - Country:US
Mailing Address - Phone:815-331-8768
Mailing Address - Fax:815-331-8760
Practice Address - Street 1:12151 REGENCY PKWY STE 12169
Practice Address - Street 2:
Practice Address - City:HUNTLEY
Practice Address - State:IL
Practice Address - Zip Code:60142-7644
Practice Address - Country:US
Practice Address - Phone:815-331-8768
Practice Address - Fax:815-331-8760
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2022-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018264101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional