Provider Demographics
NPI:1548933146
Name:SMITH, MAX
Entity type:Individual
Prefix:
First Name:MAX
Middle Name:
Last Name:SMITH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 W MAIN ST STE 6
Mailing Address - Street 2:
Mailing Address - City:OBLONG
Mailing Address - State:IL
Mailing Address - Zip Code:62449-1165
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 W MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:OBLONG
Practice Address - State:IL
Practice Address - Zip Code:62449-1165
Practice Address - Country:US
Practice Address - Phone:618-636-0719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180016323101YP2500X
IL178017178101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional