Provider Demographics
NPI:1942729215
Name:SMITH, CAROLINE MARY
Entity type:Individual
Prefix:
First Name:CAROLINE
Middle Name:MARY
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 1:1245 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2542
Mailing Address - Country:US
Mailing Address - Phone:847-431-6633
Mailing Address - Fax:
Practice Address - Street 1:1245 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-2542
Practice Address - Country:US
Practice Address - Phone:847-431-6633
Practice Address - Fax:847-431-6633
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer