Provider Demographics
NPI:1003005455
Name:SMITH, NANCI ROSE
Entity Type:Individual
Prefix:
First Name:NANCI
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NANCI
Other - Middle Name:ROSE
Other - Last Name:CAVANAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:175 W B ST
Mailing Address - Street 2:BUILDING I
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-4575
Mailing Address - Country:US
Mailing Address - Phone:541-988-1025
Mailing Address - Fax:
Practice Address - Street 1:175 W B ST
Practice Address - Street 2:BUILDING I
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-4575
Practice Address - Country:US
Practice Address - Phone:541-988-1025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2007-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR241382Medicaid