Provider Demographics
NPI:1548976558
Name:SMITH, FAITH ANNA
Entity type:Individual
Prefix:MRS
First Name:FAITH
Middle Name:ANNA
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 1:400 S SCOTT AVE
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448-1656
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2020 BROADWAY ST STE I
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2973
Practice Address - Country:US
Practice Address - Phone:618-316-7001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018855101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional