Provider Demographics
NPI:1902340730
Name:SMITH, ANNIE MICHELE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:ANNIE
Middle Name:MICHELE
Last Name:SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 E. LAKE SHORE DR.
Mailing Address - Street 2:#209
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62522-3832
Mailing Address - Country:US
Mailing Address - Phone:217-423-6500
Mailing Address - Fax:
Practice Address - Street 1:1770 E LAKE SHORE DR
Practice Address - Street 2:#209
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3832
Practice Address - Country:US
Practice Address - Phone:217-423-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0171071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical